The correct answer is A. The underlying pathology is most likely a single parathyroid adenoma, for which surgical removal is the only cure. In postmenopausal women, however, bisphosphonate therapy can be given to inhibit osteoclastic activity, which reduces bone resorption and turnover. Hydration is also an essential treatment for this condition to help decrease serum calcium levels.
Calcitonin (choice B) is useful when dealing acutely with extremely high levels of serum calcium, but long-term therapy is not routinely pursued. Resistance to its hypocalcemic effects develops within 1 or 2 days. It may have a role in the management of symptomatic osteoporotic compression fracture management, because this agent has some bone anesthesia associated with its use. The excessive cost of the oral agent make calcitonin a less commonly used agent.
Low calcium intake (choice C) can result in increased hormone production and can accentuate bone disease. Calcium intake for this woman should be adequate, but not low.
Thiazides (choice D) are contraindicated in the setting of hypercalcemia because they can worsen hypercalcemia (when diuretics are used to control excessive hypercalcemia, furosemide is recommended).
Vitamin D analogues (choice E) are used in patients who have hyperparathyroidism secondary to renal failure. Vitamin D analogs can increase the absorption of calcium, which potentially could worsen a patient who has hyperparathyroidism who already has an elevated serum calcium level.
PEARL: Patients who have hypercalcemia caused by primary hyperparathyroidism need to have serum calcium levels monitored so that if they rise to 15 mg/dL or higher, intervention can take place. When patients have hyperparathyroidism and conservative therapy is elected to pursue, adequate hydration states are essential to maintain. Definitive therapy with surgery to remove the parathyroid hormone can be performed if medical therapy fails to control the hypercalcemia. In addition to hydration therapy, bisphosphonates may be used to inhibit osteoclastic activity and reduce bone resorption. Calcitonin may be used as adjunctive short-term therapy, but its effectiveness in hypercalcemia management in patients who have primary hyperparathyroidism is short-lived and a very expensive alternative treatment.
