What is an initial management step for severe hypercalcemia?

• A. Aggressive IV hydration with normal saline
• B. Administer diuretics to eliminate calcium
• C. Immediate hemodialysis
• D. Start calcitonin as first line

Answer: (A)

The key thing being tested is how to promptly manage severe hypercalcemia. The first priority is to restore intravascular volume with aggressive IV fluids using isotonic saline. Rehydration improves kidney perfusion and increases glomerular filtration, which promotes calcium excretion (calciuresis) and helps start lowering the calcium level quickly. Hydration also corrects any dehydration that often accompanies hypercalcemia, which can worsen renal impairment and calcium retention.

Diuretics to eliminate calcium are not started before rehydration because they can worsen volume depletion and electrolyte balance; they’re considered only after hydration has been achieved if further calcium loss is needed. For rapid but temporary calcium reduction, calcitonin can be used, but its effect is short-lived. Bisphosphonates provide a longer-lasting reduction in calcium by inhibiting bone resorption, but they take longer to work and are added after initial hydration. Hemodialysis is reserved for cases where there is life-threatening hypercalcemia with renal failure or when rapid reduction is necessary and fluids/other measures are contraindicated or ineffective.

So, starting with aggressive normal saline hydration directly targets the immediate issues of volume status and renal calcium excretion, making it the best initial step.