A 68-year-old with newly diagnosed myeloma presents drowsy and dehydrated. Adjusted calcium 3.8 mmol/L. Manage.

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Symptomatic hypercalcaemia of malignancy. ABCDE, IV access, bloods including PTH, vitamin D, myeloma screen, ECG looking for short QT. I'd start IV 0.9% saline 200-300 mL/h, aiming euvolaemia over 24 hours with strict fluid balance, hourly observations and 12-hourly calcium. Once rehydrated I'd give IV zoledronate 4 mg, dose-adjusted for eGFR or substitute denosumab if eGFR <30. For severe symptoms I'd add calcitonin 4 IU/kg subcutaneously for rapid effect. I'd stop calcium, vitamin D, thiazides and lithium, and refer to haematology for definitive myeloma therapy. I'd warn about tetany once calcium falls and pre-empt with magnesium replacement. I'd have a clear conversation with the patient and family about diagnosis, prognosis and ceiling of care.

Severe symptomatic hypercalcaemia

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