Intervention | Mode of action | Onset of action | Duration of action |
Isotonic saline hydration | Restores intravascular volume Increases urinary calcium excretion | Hours | During infusion |
Calcitonin | Inhibits bone resorption via interference with osteoclast function Promotes urinary calcium excretion | 4 to 6 hours | 48 hours* |
Bisphosphonates | Inhibit bone resorption via interference with osteoclast recruitment and function | 24 to 72 hours | 2 to 4 weeks |
Loop diuretics¶ | Increase urinary calcium excretion via inhibition of calcium reabsorption in the loop of Henle | Hours | During therapy |
Glucocorticoids | Decrease intestinal calcium absorption Decrease 1,25-dihydroxyvitamin D production by activated mononuclear cells in patients with granulomatous diseases or lymphoma | 2 to 5 days | Variation duration of effect (days to weeks) |
Denosumab | Inhibits bone resorption via inhibition of RANKL | 4 to 10 days | 4 to 15 weeks |
Calcimimetics | Calcium-sensing receptor agonists, reduces PTH (parathyroid carcinoma, secondary hyperparathyroidism in CKD) | 2 to 3 days | During therapy |
Dialysis | Removes calcium, a low or no calcium dialysate should be used | Hours | Reduction of calcium during dialysis |
RANKL: receptor activator of nuclear factor kappa-B ligand; PTH: parathyroid hormone; CKD: chronic kidney disease.
* The efficacy of calcitonin is limited to the first 48 hours, even with repeated doses, due to the development of tachyphylaxis.
¶ Loop diuretics should not be used routinely. However, in patients with renal insufficiency or heart failure, judicious use of loop diuretics may be required to prevent fluid overload during saline hydration.