Clinical Case #2 Hyperparathyroidism - Pearson Flashcards
What are the risk factors for osteoporosis?
Female gender Lifelong low calcium intake Petite body frame Smoking White or Asian ancestry Excessive alcohol use Sedentary lifestyle/immobilization Long-term use of certain drugs Nulliparity (woman that has never given birth to a child) Postmenopausal status Increasing age Low body weight High caffeine intake Impaired calcium absorption Renal disease
What are the symptoms of hyperparathyroidism?
“Stones, bones, groans and moans” Back pain Blurred vision (because of cataracts) Bone pain or tenderness Decreased height Depression Fatigue Fractures of long bones Increased urine output Increased thirst Itchy skin Joint pain Loss of appetite Nausea Muscle weakness and pain Personality changes Stupor and possibly coma Upper abdominal pain
What evaluation/work up should be done in a patient given a differential diagnosis with osteoporosis and hyperparathyroidism?
***Check for secondary causes
CMP (Complete Metabolic Panel) with Calcium/Phosphorus
CBC
Vit D (25-Hyroxyvitamin D)
TSH
Sed rate
Consider 24 hour urine for Calcium/Creatinine
Bone x-rays and bone mineral density test (DEXA scan) can help detect bone loss, fractures, or bone softening.
X-rays, ultrasound, or CT scans of the kidneys or urinary tract may show calcium deposits or a blockage.
What are the National Osteoporosis Foundation Guidelines for Clinicians in evaluating and managing osteoporosis?
- In women age 65 and older and men age 70 and older, recommend bone mineral density (BMD) testing.
- In postmenopausal women and men age 50-69, recommend BMD testing when you have concern based on their risk factor profile.
- Initiate treatment in those with hip or vertebral (clinical or asymptomatic) fractures.
- Initiate treatment in postmenopausal women and men age 50 and older with low bone mass (T-score between -1.0 and -2.5, osteopenia) at the femoral neck, total hip, or spine and a 10-year hip fracture probability ≥ 3% or a 10-year major osteoporosis-related fracture probability ≥ 20% based on the US-adapted WHO absolute fracture risk model
How do you interpret DEXA Scan results, including the use of T-scores and Z-scores?
T-scores = shows the amount of bone the patient has compared to a young adult (at the age of 35) => greater than -1 is adequate bone density, -1 to -2.5 is osteopenia,
How do you differentiate primary vs. secondary causes of osteoporosis?
Primary osteoporosis—deterioration of bone mass that is unassociated with other chronic illness—is related to aging and decreased gonadal function
Secondary osteoporosis results from chronic conditions that contribute significantly to accelerated bone loss. These chronic conditions include endogenous and exogenous thyroxine excess, hyperparathyroidism, malignancies, gastrointestinal diseases, medications, renal failure and connective tissue diseases
What is the management/treatment for Hyperparathyroidism?
Tx depends upon the severity and cause of the condition.
With mildly increased calcium levels due to primary hyperparathyroidism and no symptoms, a patient may just need regular follow up.
If symptoms are present or calcium level is very high, surgery may be needed to remove the parathyroid gland that is overproducing the hormone.
Tx of secondary hyperparathyroidism depends on the underlying cause.
Indications for surgery include:
Calcium levels > 1 unit above normal
Osteoporosis: Dexa scan showing T score > 2.5 at any site
CrCl (creatinine clearance) 500 mg per 24 hours
What are the potential complications of Hyperparathyroidism?
Increased risk of fractures Urinary tract infection due to kidney stones and blockage Peptic ulcer disease Pancreatitis Pseudogout
What causes Hyperparathyroidism?
Primary hyperparathyroidism is caused by enlargement of one or more of the parathyroid glands. This leads to too much PTH, which raises the level of calcium in the blood.
Secondary hyperparathyroidism is when the body produces extra PTH because the calcium levels are too low. This is seen when vitamin D levels are low or when calcium is not absorbed from the intestines. Correcting the calcium level and the underlying problem will bring the parathyroid levels in the normal range.
What are the current recommendations on dietary Calcium intake and supplementation?
Men age 19-70 need 1,000 mg/day
Women age 19-50 need 1,000 mg/day
Women age 51+ need 1,200 mg/day
Pregnant/breast-feeding women need 1,000 mg/day
What are the current recommendations on dietary Vitamin D intake and supplementation?
Men age 19-70 need 600 mg/day
Men age 71+ need 800 mg/day
Women age 19-70 need 600 mg/day
Women age 71+ need 800 mg/day
How do you diagnose Vitamin D deficiency?
A 25-hydroxyvitamin D level should be obtained in
patients with suspected vitamin D deficiency.
Deficiency is defined as a serum 25-hydroxyvitamin D level of less than 20 ng per mL (50 nmol per L), and insufficiency is defined as a serum 25- hydroxyvitamin D level of 20-30 ng per mL (50 to 75 nmol per L).
How do you manage/treat Vitamin D deficiency?
Supplementation: oral ergocalciferol (vitamin D2) at 50,000 IU per week for eight weeks.
After vitamin D levels normalize, experts recommend maintenance dosages of cholecalciferol (vitamin D3) at 800 to 1,000 IU per day from dietary and supplemental sources.
What are the symptoms/manifestations of Vitamin D deficiency?
symmetric low back pain, proximal muscle weakness, muscle aches, and throbbing bone pain elicited with pressure over the sternum or tibia
