Purpose/Background: Hypercalcemia is a clinical condition in which serum calcium levels exceed the upper limit of normal (>10.5 mg/dL). The most common causes of hypercalcemia are primary hyperparathyroidism and malignancy, however, it can also be caused by vitamin D intoxication, endocrine disorders, and immobilization due to an increase in bone resorption. First-line treatment of hypercalcemia includes hydration with intravenous (IV) normal saline and IV bisphosphonates. Calcitonin (Miacalcin®) is a synthetic hormone with a rapid onset of action and used intramuscularly (IM) or subcutaneously (SQ) as a second-line treatment in the management of hypercalcemia, specifically in severe and in symptomatic cases. The purpose of this performance improvement initiative is to assess the prescribing practices of calcitonin at Baptist Hospital of Miami (BHM) and to optimize the utilization of calcitonin in patients with hypercalcemia by facilitating the establishment of a calcitonin prescribing criteria.
Methods: This was a single center biphasic study including both a retrospective and prospective phase of adult patients receiving calcitonin for hypercalcemia management at BHM. Phase I retrospective data was obtained from October 1st 2017 to September 30th 2019 and phase II prospective data was collected during January 6th 2020 to April 24th 2020. Data collection for both phases included patient demographics, indication, prescriber’s specialty, severity of hypercalcemia, presence or absence of symptoms, duration of therapy and use of first line therapy. Furthermore, pharmacy interventions pertaining to first line therapy usage or adjustments of duration of calcitonin as well as financial impact of accepted interventions were calculated for phase II. Primary outcome of the study included duration of calcitonin therapy for correction of hypercalcemia. Secondary outcomes included number of pharmacy interventions and percentage of patients treated with IV fluids and IV bisphosphonates.
Results: A total of 94 patients in phase I and 16 patients in phase II met study inclusion criteria. The baseline demographics were primarily differentiated by the severity of hypercalcemia in the two phases. A greater proportion of patients in phase I (43.6%) was noted to have severe hypercalcemia compared to phase II (18.8%). In both phases, hypercalcemia of malignancy and oncology specialty accounted for the most common indication and prescriber specialty, respectively. In terms of primary outcome, duration of calcitonin therapy was significantly improved through pharmacist interventions in phase II as evidenced by 0% of patients receiving calcitonin beyond 48 hours versus 28.7% of patients in phase I (p= 0.0107). Evaluation of first line therapy demonstrated that 81% of patients received IV fluids and 88% of patients received IV bisphosphonate therapy in phase I while 100% of the patients in phase II received both IV fluids and IV bisphosphonates (p= 0.0689; p= 0.3613). In phase II, a total of 16 pharmacy interventions were performed with 75% acceptance rate including discontinuation or reduction in duration of calcitonin therapy and addition of IV fluids. These interventions resulted in 29 calcitonin doses avoided during phase II study period that amounts to an extrapolated annual cost savings of ~ $158,000.
Conclusion: Implementation of a calcitonin prescribing criteria through prospective pharmacist review and recommendations can facilitate the optimization of calcitonin use in patients with hypercalcemia at BHM and potentially lead to significant cost savings.
BHSF Pharmacy Residency Conference
Jessica Hernandez - Pharmacy Resident PGY1
Hernandez, Jessica; Gopalani, Radhan; Clarke, Heidi; Lee, Joyce; and Donadio, Alyssa, "Calcitonin prescribing criteria for the management of hypercalcemia in a community hospital" (2020). All Publications. 3526.
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