Overview of session

Calcium, vitamin D and hyperparathryoidism

2. Background 3. History and assessment

Dr Asjid Qureshi Consultant in Endocrinology and Diabetes

4. Management

Tel: 020 8869 2641; Mob: 07960 27 87 07 [email protected]

5. Case studies

www.endocrinologyspecialist.com

PRIVATE PRACTICE The Garden Hospital 46/50 Sunny Gardens Road, Hendon, London, NW4 1RP

1. Case study

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NHS PRACTICE Northwick Park Hospital Tel: 020 8869 2622/3 Fax: 020 8869 2961

in “presentations” in section for “GPs”

Case Study  35yr man  Aches/pains/tiredness  BP 148/93

Cr 87mmol/l Ca 2.53mmol/l AlkP: normal

Background

Phos: low

 Hypertension  Bendrofluazide 2.5mg od

PTH 2.3pmol/l Vitamin D 12nmol/l

 DNAed follow-up

Sources of vitamin D  Food – Vitamin D2  UV light mediated cholesterol metabolism – D3 

Oily fish – trout, salmon, mackerel, sardines, tuna

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Cod liver oil

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Egg yolk

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Mushrooms

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Supplemented serials

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Only infant milk and margarine have statutory supplementation (320IU per 100gm)

Definition Serum 25-OH vit-D

Vit-D status

75nmol/l

Ideal

Prevalence  50% of UK population have low Vit D levels

At risk populations 

 16% - severe deficiency during winter/spring  Highest in,  Scotland  Northern England and Ireland

 6-9 months (Oct – Apr) per yr, 90% UK does not

Ethnic minorities 

pigmented skin

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Cultural/religous

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Elderly

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Institutionalised

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Malabsorption

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Drugs – e.g. anti-convulsants

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Vegetarian

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Sun factor 15 or more blocks 99% of vit-D synthesis

receive adequate UVB light exposure

Associations  Bone/muscle symptoms  Overall mortality

Vitamin D assay

 Cardiovascular disease  Type 1 and 2 diabetes  Cancer – breast, bowel  MS

Vitamin D assay

25-OH vit-D - seasonal variability

 Measure 25-OH vit-D  Most reliable for diagnosis  Seasonal variation

Cannell JJ, Vieth R, Umhau JC,et al. Epidemiol Infect. 2006

History  Age, ethnicity

History and assessment

 Mobility/independence/institutionalise  Diet  Oily fish, egg yolks, cod liver oil and fresh meat

 Medication: (P450 enzyme inducing drugs eg rifampicin and phenytoin) and warfarin  Consider the possibility of pregnancy

Investigations  Assessment of vitamin D status  25(OH)vitamin D (low)

Investigations

 Cca (normal/low)  PO4 (normal/low)  AlkP (normal/raised)  PTH (normal in 20%)

 Secondary investigations  U&Es  LFTs and FBC

Pitfalls  Co-existent diagnosis suspected

Pitfalls

 Masked causes of hypercalcaemia  Primary hyperparathyroidism  Malabsorption (FBC/LFTs/etc.)

 Exclude renal disease  Investigate as appropriate

How to maintain adequate levels  Daily recommendation 400IU of vitamin D

Treatment

 20-30min sunlight to face and forearms at midday generates 2000IU of vitamin D  2 – 3 such exposures per week  2-10 fold greater exposure in pigmented patients

Preparations

Tablet preparations

 Drops

 Ergocalciferol (calciferol) – vitamin D2

 Colecalciferol 400IU per 0.6ml

 Colecalciferol (Cholecalciferol) – vitamin D3

 Tablets

 1 alfacalcidol (1, OH-Vit-D)

 Ca (400mg) and ergocalciferol (400IU)

 renal disease

 Colecalciferol

 hypoparathyroidism

 Ergocalciferol

 Calcitriol – (1,25-OH-Vit-D)

 1-alfacalcidol

 renal disease

 Parenteral

 hypoparathyroidism

 Ergocalciferol 300,000IU per ml

 Severe hypoalcaemia

Treatment  Deficiency 

Hyperparathyroidism and vitamin D deficiency

Restoration over 12 weeks  10,000IU calciferol per day OR  60,000IU calciferol per week OR  300,000IU im monthly for 3 months



Then maintain with  1000-2000IU Calciferol daily or  10,000IU weekly  300,000IU 1-2 times per year

 Insufficiency 

1000-2000IU calciferol daily OR



10,000IU calciferol per week Therapy is life - long

Hyperparathyroidism

Primary Hyperparathyroidism

 Primary – parathyroid adenoma/hyperplasia  Secondary – in response to hypocalcaemia

 Incidence:  1 per 1000 men

 Tertiary – autonomous PTH secondary to

 2-3 per 1000 women

 renal disease

 Incidence increases above age 40

 Prolonged profound vitamin D deficiency

 >80% - solitary parathyroid adenoma  Hyperplasia / double adenoma

Primary HPT: Clinical Features

Investigations

 Asymptomatic  Symptomatic

 Nephrolithiasis  Fractures  Hypercalcemia  Fatigue  Muscle weakness  Depression  Increased thirst  Polyuria  Constipation  Aches and pains

Surgical Candidacy  Symptomatic primary HPT  Asymptomatic HPT  Serum calcium >0.25mmol/l above upper limit

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Bone profile

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Intact PTH

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24hr urine calcium

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Calcium excretion ratio

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Bone mineral density scan

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Renal US

Familial Hypocalciuric Hypercalcemia  “Benign” condition  Easily mistaken for PHP  Autosomal dominant  Characterized by

 Osteoporosis

 Hypocalciuria (calcium excretion ratio