›Maximum 4000 mg per 24 hours
›Lower maximum in liver disease
›NSAID option when appropriate
›Ibuprofen PO 400 mg every 6 to 8 hours
›Avoid in advanced CKD or high bleeding risk
›Opioid for severe pain
›Morphine IV 0.05 mg per kg
›Repeat every 10 to 15 minutes to effect
›Monitor for hypotension and respiratory depression
›Hydromorphone IV 0.2 mg
›Repeat every 10 to 15 minutes to effect
›Use lower doses in opioid naive
›Regional anesthesia option
›Femoral nerve block for femur fracture
›Fascia iliaca block for hip region pain
›Antiemetic for opioid related nausea
›Ondansetron IV 4 mg
›Repeat every 8 hours as needed
›QT prolongation caution
Etiology directed medical therapy
›Malignant hypercalcemia management
›Initial therapy
›Isotonic saline IV 1000 mL bolus
›Repeat bolus based on volume status
›Ongoing infusion 150 to 250 mL per hour target
›Calcitonin SC or IM 4 units per kg every 12 hours
›If inadequate response, 8 units per kg every 12 hours
›Tachyphylaxis after 48 to 72 hours
›Antiresorptive therapy
›Zoledronic acid IV 4 mg once
›Onset 24 to 48 hours
›Renal dose considerations
›Pamidronate IV 60 mg once
›Alternative to zoledronic acid
›Slower onset
›Denosumab SC 120 mg once
›Consider if bisphosphonate refractory
›Consider in significant renal dysfunction
›Adjuncts
›Loop diuretic only after euvolemia
›Dialysis for refractory severe hypercalcemia with renal failure
›Suspected pathologic fracture from infection
›Antibiotic timing
›If unstable or septic, initiate immediately after cultures
›If stable, coordinate cultures and biopsy before antibiotics when feasible
›Empiric coverage examples
›Vancomycin IV 15 mg per kg
›Trough guided dosing per local protocol
›Renal adjustment required
›Ceftriaxone IV 2 g daily
›Broad gram negative coverage adjunct
›Adjust per local antibiogram
›Evidence notes
›Spinal cord compression steroids supported by guideline consensus
›Class I recommendation in many oncology pathways
›Earlier administration associated with symptom stabilization
›Open fracture antibiotics supported by trauma guidelines
›Early antibiotics associated with lower infection rates
›Class I recommendation in trauma society guidance