Nephrocalcinosis Medication

Updated: Dec 07, 2015
  • Author: Tibor Fulop, MD, FASN, FACP; Chief Editor: Vecihi Batuman, MD, FASN  more...
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Medication

Medication Summary

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

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Diuretics, Thiazide

Class Summary

Thiazide diuretics are extremely helpful in decreasing calcium excretion in several conditions associated with nephrocalcinosis. Hydrochlorothiazide, the most commonly employed thiazide diuretic, is appropriate to use if the serum calcium level is not high; it may correct coincidental high blood pressure. The usual dose range is 12.5-25 mg/day, though in rare cases it can reach 50 mg/day. However, if hydrochlorothiazide is used, it should be given in 2 divided doses to cover a full 24-hour period.

Hydrochlorothiazide (Microzide)

Hydrochlorothiazide inhibits reabsorption of sodium in the distal tubules, causing increased excretion of sodium and water, as well as of potassium and hydrogen ions.

Chlorthalidone

Chlorthalidone inhibits reabsorption of sodium in distal tubules, causing increased excretion of sodium and water, as well as of potassium and hydrogen ions. It reduces calcium excretion through direct tubular effects.

Chlorothiazide (Diuril)

A thiazide diuretic, chlorothiazide inhibits sodium-chloride symport, blocking sodium reabsorption in the distal convoluted tubule.

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Calcium Metabolism Modifiers

Class Summary

Bisphosphonates are used to treat hypercalcemia and to decrease calcium loss from bone.

Calcitonin is indicated for treatment of hypercalcemia. It maintains calcium homeostasis by increasing the mineral stores in bone and the renal excretion of calcium. Calcitonin also directly inhibits osteoclastic bone resorption. Because of its longer duration of action, salmon calcitonin is preferred to human calcitonin.

Pamidronate (Aredia)

Inhibits bone resorption via actions on osteoclasts or on osteoclast precursors, without significant effects on renal tubular calcium handling. Indicated to treat hypercalcemia.

Alendronate (Fosamax, Binosto)

Alendronate has been successful in treating the pain of polyostotic fibrous dysplasia; it may have some benefit in increasing bone mineral density as well. It offers the additional benefit of oral administration.

Ibandronate (Boniva)

Ibandronate increases bone mineral density and reduces the incidence of vertebral fractures. Ibandronate increases bone mineral density at the spine by 5.7-6.5% and the hip by 2.4-2.8%. It reduces vertebral fractures by 50% with intermittent (nondaily) dosing over 3 years; it has no effects on reduction of nonvertebral fractures. Ibandronate is approved for the treatment and prevention of postmenopausal osteoporosis. It is available as a 150-mg oral tablet and intravenous solution.

Risedronate (Actonel, Atelvia)

Risedronate is a potent antiresorptive agent that does not affect bone mineralization. The inclusion of an amino group within the heterocyclic ring makes risedronate one of the most potent antiresorptive bisphosphonates. As with other bisphosphonates, risedronate inhibits osteoclast formation and activity. Risedronate increases bone mineral density at the spine by 5.4% and the hip by 1.6%. It reduces vertebral fractures by 41% and nonvertebral fractures by 39% over 3 years. It is approved for the treatment and prevention of postmenopausal osteoporosis, male osteoporosis, and glucocorticoid-induced osteoporosis.

Zoledronic acid (Reclast)

Zoledronic acid inhibits bone resorption by altering osteoclast activity and by inhibiting normal endogenous, as well as tumor-induced, mediators of bone degradation. Like other bisphosphonates, zoledronic acid binds to hydroxyapatite crystals in mineralized bone matrix. The binding to calcium phosphates slows the dissolution of hydroxyapatite crystals, as well as inhibits the formation and aggregation of these crystals. It increases bone mineral density at the spine by 4.3-5.1% and at the hip by 3.1-3.5%, as compared with placebo. It reduces the incidence of spine fractures by 70%, hip fractures by 41%, and nonvertebral fractures by 25% over 3 years. Zoledronic acid is approved for the treatment and prevention of postmenopausal osteoporosis, glucocorticoid-induced osteoporosis, osteoporosis in men, and Paget disease of bone. It is contraindicated in patients with severe renal failure.

Calcitonin (Miacalcin, Fortical)

Calcitonin lowers elevated serum calcium in patients with multiple myeloma, carcinoma, or primary hyperparathyroidism. A higher response can be expected when serum calcium levels are high. Onset of action is approximately 2 hours after injection, and activity lasts for 6-8 hours. Calcitonin may lower calcium levels by about 9% for 5-8 days if administered every 12 hours. If it is administered intramuscularly (IM), it should be injected at multiple sites in doses greater than 2 mL.

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Vitamins

Class Summary

Pyridoxine (vitamin B-6) deficiency is a known cause of hyperoxaluria. Used to treat nephrocalcinosis, pyridoxine decreases calcium oxalate formation and the subsequent development of kidney stones.

Pyridoxine (Pyri 500, Neuro-K500)

Pyridoxine is involved in the synthesis of gamma-aminobutyric acid (GABA) within the central nervous system (CNS).

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Antimalarial Agent

Class Summary

Hydroxychloroquine can be helpful in controlling hypercalcemia due to sarcoid and is utilized as a glucocorticoid-sparing agent.

Hydroxychloroquine (Plaquenil)

Hydroxychloroquine may be most useful in the management of osseous involvement. It inhibits chemotaxis of eosinophils and locomotion of neutrophils, and it impairs complement-dependent antigen-antibody reactions.

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Calcimimetic Agent

Class Summary

Calcimimetic agents can be used in primary hyperparathyroidism for temporary control of hypercalcemia if a patient is a poor surgical risk or if surgery is not immediately available. Experience in such settings is limited.

Cinacalcet (Sensipar)

Cinacalcet directly lowers parathyroid hormone (PTH) levels by increasing the sensitivity of calcium-sensing receptors on chief cells of the parathyroid gland to extracellular calcium. It also results in a concomitant serum calcium decrease. It is indicated for hypercalcemia with parathyroid carcinoma.

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Alkalinizing Agent, Oral

Class Summary

Oral alkalizing agents are used for urinary alkalization.

Sodium citrate (Bicitra, Oracit)

Sodium citrate treats metabolic acidosis and used as alkalizing agent where long-term maintenance of alkaline urine is desirable.

Potassium citrate (Citra-K)

Potassium citrate is an alkalizing agent indicated for treatment of systemic metabolic acidosis, urinary alkalization, or hypocitraturia. It is administered orally and is metabolized to bicarbonate in the liver. Each 5 mL of Polycitra contains sodium citrate 500 mg, citric acid 334 mg, and potassium citrate 550 mg (amounting to 5 mEq of potassium, 5 mEq of sodium, and 10 mEq of bicarbonate).

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