ORIGINAL ARTICLE

COMPARISON OF CALCITRIOL VERSUS CHOLECALCIFEROL

THERAPY IN ADDITION TO ORAL CALCIUM AFTER TOTAL
THYROIDECTOMY WITH CENTRAL NECK LYMPH NODE
DISSECTION: A PROSPECTIVE RANDOMIZED STUDY
Jun-Ho Choe, MD,1 Wan Wook Kim, MD,2 Se-Kyung Lee, MD,1 Hye In Lim, MD,3
Jae Hyuck Choi, MD,4 Jeong Eon Lee, MD,1 Jung-Han Kim, MD,1 Seok Jin Nam, MD,1
Jung-Hyun Yang, MD,1 Jee Soo Kim, MD1
1
Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
E-mail: jskim0126@skku.edu
2
Department of Surgery, Kyungpook National University Hospital, Daegu, Korea
3
Department of Surgery, Bundang Jesaeng General Hospiral, Gyeonggi, Korea
4
Department of Surgery, Jeju National University Hospital, Jeju, Korea

Accepted 12 August 2010

Published online 29 November 2010 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/hed.21619

sensation of the limbs, perioral numbness, to spasms

Abstract: Background. The purpose of this study was to
determine the effectiveness of oral calcium plus vitamin D sup-
plementation and to compare the effects of cholecalciferol ver-
sus calcitriol treatments on postoperative hypocalcemia.
Methods. After total thyroidectomy with central neck dis-
section, 306 patients were divided into 4 groups according to
‘‘routine use versus on-demand use’’ and ‘‘cholecalciferol ver-
sus calcitriol.’’
Results. Hypocalcemic symptoms developed in 101
patients (33.0%). Hypocalcemia developed less frequently in
patients receiving routine supplementation regardless of vita-
min D type. However, routine supplementation did not prevent
severe hypocalcemia. In patients receiving on-demand supple-
ments, calcitriol was more effective and faster acting than was
cholecalciferol.
Conclusion. Routine oral calcium and vitamin D supplements
are beneficial after total thyroidectomy with central neck lymph
node dissection with no difference between cholecalciferol and
calcitriol. If taken after the onset of hypocalcemia, however, calci-
triol along with calcium carbonate seems to be more effective than
is cholecalciferol with calcium carbonate. V C 2010 Wiley
Periodicals, Inc. Head Neck 33: 1265–1271, 2011
Keywords: cholecalciferol; calcitriol; total thyroidectomy; oral
calcium; central neck dissection
Postoperative hypocalcemia caused by hypoparathyr-
oidism is 1 of the most common and agonizing compli-
cations after total thyroidectomy. The reported
incidences of transient and permanent hypoparathyr-
oidism are 6.9% to 75%1,2 and 0% to 8%3, respectively.
Hypocalcemic symptoms range from a mild tingling
Correspondence to: J. S. Kim
Jun-Ho Choe and Wan Wook Kim contributed equally to this work.
V
C 2010 Wiley Periodicals, Inc.
of the hands, feet, and facial muscles. Calcium
replacement therapy, lengthy hospitalization, and
even readmission may be necessary in severe cases.
Routine postoperative calcium supplementation after
total thyroidectomy can prevent patients from experi-
encing hypocalcemic symptoms and can improve post-
operative quality of life.4–7
Postoperative serum calcium (Ca), ionized-calcium
(i-Ca), and intact parathyroid hormone (i-PTH) are
reliable early predictors for hypocalcemia.8 It is
reported that hypocalcemia can be prevented by pro-
viding oral calcium and vitamin D supplements in all
patients after total thyroidectomy.4–7 Few studies
have been conducted to compare the effects of the 2
different forms of vitamin D, calcitriol, and cholecal-
ciferol on postoperative hypocalcemia. With advances
in surgical technology for conserving the parathyroid
glands, the incidence of severe postoperative hypocal-
cemia has decreased, but a number of cases still occur
after total thyroidectomy, especially when combined
with central neck lymph node dissection.
The purposes of this study were to (1) determine
whether routine supplemental oral calcium therapy
with vitamin D is helpful for all patients after total
thyroidectomy plus central neck lymph node dissec-
tion, and (2) analyze the type of vitamin D supple-
ment, cholecalciferol or calcitriol, that was more
effective in the prevention and improvement of post-
operative hypocalcemia.
PATIENTS AND METHODS
In this prospective randomized controlled study, we
enrolled 306 patients who had undergone total thy-
roidectomy due to malignant disease. Total thyroidec-
tomies were performed by 3 experienced surgeons at

Calcitriol vs Cholecalciferol on Post-Thyroidectomy Hypocalcemia HEAD & NECK—DOI 10.1002/hed September 2011 1265
 Table 1. Patient groupings.

Group No. of patients Oral calcium* Vitamin D Remarks

A
A1 72 Calcium carbonate Cholecalciferol‡ Routine supply
A2 82 Calcium carbonate Calcitriol† Routine supply
B
B1 72 Calcium carbonate Cholecalciferol‡ Supply on demand
B2 80 Calcium carbonate Calcitriol† Supply on demand
Total 306 – – –
*Calcium carbonate 3.0 g/day.
†
Calcitrol 0.5 lg/day.
‡
Cholecalciferol 20 lg/day.

the Samsung Medical Center between July and No-
vember 2008. Patients with a history of preoperative
oral calcium supplement use, renal or urinary tract
disease, prior thyroid or parathyroid surgery, neck
radiation therapy, and benign disease were excluded
from the study. For all patients, we carried out cen-
tral neck node dissection. To compare the effect of
routine oral calcium and vitamin D supplementation,
we divided the patients into 2 groups: group A, rou-
tine supplied group; group B, calcium supplied on-
demand. Furthermore, to analyze the efficacy
between calcitriol and cholecalciferol, the patients in
each group A and B were subdivided into A1 and A2,
B1 and B2, respectively. Patients were randomly
assigned to 1 of the groups (Table 1). Patients in
groups A1 and B1 received a mixture of calcium car-
bonate (1500 mg) and cholecalciferol (10 lg; Hardcal,
Bukwang Pharmaceutical, Seoul, South Korea), a
chewable tablet that is taken orally as 1 tablet twice
a day. Patients in groups A2 and B2 received calcium
carbonate (500 mg; Tai Guk Pharmaceutical, Seoul,
South Korea) taken orally as 2 tablets 3 times a day
and calcitriol (0.25 lg; Bonky; Yu Yu Pharmaceutical,
Seoul, South Korea) taken orally as 2 capsules once a
day. Calcitriol, 1,25-dihydroxycholecalciferol, is the
active form of cholecalciferol, which is metabolized in
the liver and kidneys.
The demographic and pathologic characteristics
and perioperative calcium profiles of all participants
were analyzed. Hypocalcemic symptoms were catego-
rized as mild, moderate, or severe. Mild symptoms
were defined as a mild tingling sensation and numb-
ness of the hands or feet. Moderate symptoms were
defined as a moderate tingling sensation, perioral
numbness, and a positive Chvostek sign. Severe
symptoms were defined as a positive Trousseau sign,
tetany, and carpopedal spasms. We monitored Ca, i-
Ca, phosphorus, and i-PTH levels on the operative
day, postoperative days 1 and 2, and postoperative
days 10 to 20.
In the A groups (A1 and A2), the group that
received routine calcium and calcitriol/cholecalciferol
supplementation, we injected calcium gluconate if Ca
<7.5 mg/dL or i-Ca <0.8 mmol/L was combined with
mild to severe hypocalcemic symptoms (Figure 1). In
the B groups, we supplemented with an oral calcium
and cholecalciferol/calcitriol combination when
patients showed Ca <8.0 mg/dL and i-Ca <1.0 mmol/
L with any degree of hypocalcemic symptoms. We
injected calcium gluconate if the patient had severe
or worsening hypocalcemic symptoms combined with
Ca <7.5 mg/dL and i-Ca <0.8 mmol/L (Figure 2). We
monitored the laboratory changes and symptom
improvements 6 hours after supplementation of oral
or intravenous calcium in both groups. On the day of
discharge, usually postoperative days 2 to 3, we pre-
scribed calcium if the patient’s Ca was <8.0 mg/dL or
i-Ca was <1.0 mmol/L and instructed the patients to
take the medication only when symptoms were present.

FIGURE 1. Sequence for the treatment of hypocalcemia in the A groups. In the A groups, patients were routinely supplied with calcium
and, a vitamin D analogue, either cholecalciferol or calcitriol, regardless of hypocalcemic symptoms. Ca, calcium; i-ca, ionized calcium;
i-PTH, intact parathyroid hormone.

1266 Calcitriol vs Cholecalciferol on Post-Thyroidectomy Hypocalcemia HEAD & NECK—DOI 10.1002/hed September 2011
FIGURE 2. Sequence for the treatment of hypocalcemia in the B groups. In the B groups, patients were supplied with calcium and a
vitamin D analogue, either cholecalciferol or calcitriol, only when hypocalcemic symptoms developed. Ca, calcium; i-ca, ionized cal-
cium; i-PTH, intact parathyroid hormone.

We used the t test to compare continuous variables
between each group and the chi-square test for categor-
ical variable analysis. Analyses were conducted using
SPSS 17.0 for Windows. A p value < .05 was considered
statistically significant. The Samsung Medical Center
Institutional Review Board approved this study.
RESULTS
Of the 306 patients enrolled in our study, the female-
to-male ratio was approximately 3:1, with a mean age
of about 49 years (range, 20–74 years). Most patients
(99.0%) had papillary thyroid carcinomas; other diag-
noses included medullary carcinoma in 2 patients, and
papillary and follicular carcinoma in 1 patient. About
one-half of the patients with malignancies (147 patients)
had lymph node metastases (48.0%). The clinicopatho-
logic characteristics and postoperative laboratory find-
ings showed no differences between groups (Table 2).
Routine versus On-Demand Uses of Calcium and
Vitamin D. Hypocalcemic symptoms developed in
101 patients (33.0%) after total thyroidectomy. Most
symptoms were mild, with moderate or severe symp-
toms occurring in only 13 patients. Calcium gluconate
injections were necessary in 43 patients (14.1%); 34
patients needed only 1 injection, whereas 3 patients
required more than 3 injections. Laboratory hypo-
calcemia was observed in 81 patients (26.5%). In this
study, the surgeon factor had no influence on postopera-
tive hypocalcemic outcomes (data not shown).
To evaluate the difference in routine administra-
tion compared to on-demand use, we compared the A
and B groups (Table 3 and Figure 3). Laboratory and
symptomatic hypocalcemia developed less frequently
in the A groups than it did in the B groups. However,
the numbers of patients with severe hypocalcemic symp-
toms or who needed intravenous calcium gluconate were
not different between the 2 groups, implying that routine
supplementation of both oral calcium and vitamin D
does not prevent severe symptomatic hypocalcemia. The
effect of prevention of hypocalcemia was most prominent
and longer lasting when the supplementation was per-
formed on postoperative day 2. No positive or negative
effect was detected for i-PTH recovery.

Table 2. Clinicopathologic characteristics and postoperative laboratory findings of the patients (n ¼ 306).

Variable Group A1 (n ¼ 72) Group A2 (n ¼ 82) Group B1 (n ¼ 72) Group B2 (n ¼ 80) p value

Age, y 48.3
10.8 48.1
8.1 49.2
10.9 48.5
9.7 NS

Sex, F:M 55:17 56:26 56:16 63:17 NS
Tumor size, cm 0.9
0.6 0.9
0.6 1.1
0.6 1.0
0.6 NS
No. of dissected lymph nodes 9.9
6.7 9.7
6.7 10.8
6.9 10.0
6.9 NS
TNM classification
I 39 43 32 34 NS
II 0 1 1 0 NS
III 33 38 39 45 NS
IV 0 0 0 1 NS
No. of parathyroid glands removed* 0.4
0.8 0.4
0.6 0.4
0.7 0.4
0.6 NS
Albumin (preoperative), g/dL 4.2
0.2 4.1
0.2 4.2
0.2 4.2
0.2 NS
Phosphorus POD #1, mg/dL 3.9
0.6 3.9
0.7 3.8
0.8 3.9
0.7 NS
Abbreviations: NS, not significant; POD, postoperative day.
Note: A p value < .05 was considered significant. Group A1 routinely supplemented with calcium carbonate and cholecalciferol (Hardcal); group A2, routinely supplemented
with calcium carbonate and calcitriol; group B1, supplemented with calcium carbonate and cholecalciferol (Hardcal) on request; group B2, supplemented with calcium carbon-
ate and calcitriol upon request.
*In case of discoloration or autotransplantation, we consider it half removed (0.5).

Calcitriol vs Cholecalciferol on Post-Thyroidectomy Hypocalcemia HEAD & NECK—DOI 10.1002/hed September 2011 1267
 Table 3. Comparison between the A and B groups.*

Variable A groups (n ¼ 154) B groups (n ¼ 152) Total (n ¼ 306) p value

Laboratory hypocalcemia 31 (20.1%) 50 (32.9%) 81 (26.5%) .014

Symptoms 36 (23.4%) 65 (42.8%) 101 (33.0%) .000
Mild 35 (22.7%) 53 (34.9%) 88 (28.8%)
Moderate 0 (0.0%) 10 (6.6%) 10 (3.3%)
Severe 1 (0.6%) 2 (1.3%) 3 (1.0%)
Additional oral calcium replacement – 65 (44.2%)
Calcium gluconate IV 16 (10.4%) 27 (17.8%) 43 (14.1%) .071
Postoperative
Calcium, mg/dL 8.50
0.43 8.54
0.42 .463
i-ca, mmol/L 1.12
0.04 1.13
0.04 .086
i-PTH, pg/mL 11.7
9.11 11.8
10.56 .970
POD #1
Calcium, mg/dL 7.88
0.55 7.87
0.50 .836
i-ca, mmol/L 1.06
0.06 1.06
0.07 .822
i-PTH, pg/mL 12.1
8.54 12.6
10.55 .629
POD #2
Calcium, mg/dL 8.14
0.63 7.90
0.61 .003
i-ca, mmol/L 1.08
0.08 1.05
0.09 .008
POD #10–20
Calcium, mg/dL 8.96
0.59 8.87
0.61 .206
i-ca, mmol/L 1.20
0.07 1.18
0.08 .045
i-PTH, pg/mL 16.2
10.34 18.4
11.48 .098
Abbreviations: i-ca, ionized calcium; i-PTH, intact parathyroid hormone; POD, postoperative day.
*A groups, routine calcium supplementation group; B groups, calcium supplementation on request.

Cholecalciferol versus Calcitriol Effect in the A
Groups. To evaluate the effect of 2 different forms of
vitamin D, we compared individuals in groups A1 and
A2. In these groups, we supplied oral calcium and
vitamin D routinely before the development of hypo-
calcemic symptoms. No significant differences were
noticed in the development of laboratory or sympto-
matic hypocalcemia or calcium and i-PTH profiles,
indicating that, if administrated routinely, cholecalcif-
erol and calcitriol plus oral calcium have similar pre-
ventive effects on postoperative hypocalcemia.
Neither group showed hypercalcemia or any effect on
the recovery of i-PTH (Table 4 and Figure 4).
Cholecalciferol versus Calcitriol Effect in the B
Groups. To compare the effects of cholecalciferol and
calcitriol on postoperative hypocalcemia after develop-
ment of hypocalcemia, we selected the patients in the
B groups who had developed hypocalcemic symptoms
and who required oral calcium and vitamin D. A total
of 65 patients (44.2%) received oral supplements. Cal-
cium and i-Ca levels were significantly higher in group
B2 (calcitriol). Six hours after receiving oral supple-
ments, Ca and i-Ca levels were slightly higher in group
B2 than in group B1, although the differences were not
statistically significant (Table 5 and Figure 4). These
findings indicate that calcitriol is more potent and pos-
sibly faster in restoring serum calcium level than is
cholecalciferol.
DISCUSSION
Hypocalcemia is 1 of the common and major complica-
tions after total thyroidectomy. Laboratory hypocalce-
mia is generally defined as Ca <8.0 mg/dL and i-Ca

FIGURE 3. Changing patterns of serum calcium, ionized calcium between the A and B groups. Significant differences were seen in (A) total
calcium on postoperative day #2 (p ¼ .003) and (B) i-calcium on postoperative day #2 (p ¼ .008) and postoperative day #10 to 20 (p ¼ .045).

1268 Calcitriol vs Cholecalciferol on Post-Thyroidectomy Hypocalcemia HEAD & NECK—DOI 10.1002/hed September 2011
 Table 4. Comparisons between groups using multiple comparison tests.*

Variable Group A1 (n ¼ 72) Group A2 (n ¼ 82) Group B1 (n ¼ 72) Group B2 (n ¼ 80) p value

Laboratory hypocalcemia 16 (22.2%) 15 (18.3%) 25 (34.7%) 25 (31.2%) .074

Symptoms 20 (27.8%) 16 (19.5%) 28 (39.8%) 37 (46.2%) .002
Mild 19 (26.4%) 16 (19.5%) 23 (31.9%) 30 (37.5%) –
Moderate 0 (0.0%) 0 (0.0%) 4 (5.6%) 6 (7.5%) –
Severe 1 (1.4%) 0 (0.0%) 1 (1.4%) 1 (1.2%) –
Additional oral calcium replacement – – 29 (41.4%) 36 (46.8%) .618
Ca gluconate IV 8 (11.1%) 8 (9.8%) 11 (15.3%) 16 (20.0%) .241
Postoperative
Calcium, mg/dL 8.51
0.43 8.50
0.44 8.48
0.38 8.60
0.45 .332
i-ca, mmol/L 1.11
0.05 1.12
0.04 1.12
0.04 1.13
0.05 .322
i-PTH, pg/mL 10.95
8.87 12.51
9.24 12.30
10.96 11.39
10.23 .737
POD #1
Calcium, mg/dL 7.84
0.57 7.92
0.53 7.84
0.49 7.89
0.51 .760
i-ca, mmol/L 1.06
0.07 1.07
0.06 1.06
0.06 1.06
0.07 .809
i-PTH, pg/mL 11.36
7.87 12.75
9.09 13.21
11.09 12.14
10.10 .689
POD #2
Calcium, mg/dL 8.12
0.62 8.16
0.64 7.85
0.67 7.94
0.55 .020
i-ca, mmol/L 1.08
0.08 1.09
0.08 1.04
0.10 1.06
0.08 .040
POD #10–20
Calcium, mg/dL 8.86
0.68 9.04
0.49 8.74
0.68 8.99
0.53 .012
i-ca, mmol/L 1.19
0.08 1.20
0.05 1.17
0.09 1.19
0.06 .041
i-PTH, pg/mL 16.26
7.10 16.17
12.55 19.76
10.95 17.27
11.91 .224
Abbreviations: i-ca, ionized calcium; i-PTH, intact parathyroid hormone; POD, postoperative day.
*Subgroup analysis that showed statistical differences.
1) POD #2
Calcium: A1 versus B1 (p ¼ .020), A2 versus B1 (p ¼ .011), A2 versus B2 (p ¼ .043).
i-ca: A1 versus B1 (p ¼ .030), A2 versus B1 (p ¼ .021).
2) POD #10–20
Calcium: A2 versus B1 (p ¼ .004), B1 versus B2 (p ¼ .022).
i-ca: A2 versus B1 (p ¼ .005).
i-PTH: A2 versus B1 (p ¼ .046).

<1.0 mmol/L. Although laboratory hypocalcemia is
frequently observed, hypocalcemic symptoms are not
always evident after total thyroidectomy.
The causes of hypocalcemia include direct intra-
operative injury to the parathyroid glands because of
difficulty discriminating fat tissue, unexpected extirpa-
tion, feeding vessel injury, or postoperative hematoma.9
It is known that permanent hypocalcemia does not de-
velop if at least 1 intact parathyroid gland is preserved,
and hypocalcemia is usually transient. In most cases,
recovery occurs within a few months, but 1% to 5% of
patients experience permanent hypocalcemia.10
If patients at risk for hypocalcemia are screened
early, they can be treated with oral calcium and vita-
min D before the onset of hypocalcemic symptoms.
Many studies have reported predictors of hypocalce-
mia after total thyroidectomy. Park and Park8
reported that postoperative Ca, i-Ca, and i-PTH levels
were reliable early predictors of treatment-requiring
hypocalcemia. Lindblom et al11 reported that a below

FIGURE 4. Changing patterns of serum calcium, ionized calcium, and parathyroid hormone levels. Levels of serum calcium and ionized
calcium began to rise on postoperative day 2. Intact parathyroid hormone levels were not different between groups. *, **, #: p < .05

Calcitriol vs Cholecalciferol on Post-Thyroidectomy Hypocalcemia HEAD & NECK—DOI 10.1002/hed September 2011 1269
 The incidence of symptomatic hypocalcemia in the
Table 5. Comparison of patients in the B groups who required oral
calcium replacement. current study was relatively high (33.0%). This may
be because we have performed central neck lymph
Group B1 Group B2 node dissection more extensively for patients with
Variable (n ¼ 29)* (n ¼ 36)* p value
papillary thyroid carcinomas. Actually, the average
Postoperative numbers of lymph nodes dissected were around 10.
Calcium, mg/dL 8.34
0.39 8.47
0.44 .023
i-ca, mmol/L 1.11
0.04 1.11
0.06 .985
Roh et al6,7 reported that central neck lymph node
i-PTH, pg/mL 4.92
4.13 5.71
6.11 .555 dissection caused a higher incidence of transient
POD #1 hypocalcemia, not permanent hypocalcemia, than the
Calcium, mg/dL 7.60
0.51 7.55
0.49 .700 lack of central neck lymph node dissection. Special
i-ca, mmol/L 1.01
0.05 1.02
0.07 .650
i-PTH, pg/mL 4.81
4.01 5.26
4.48 .689
concern to preserve the parathyroid glands and their
POD #2 blood supply is required during total thyroidectomy
Calcium, mg/dL 7.44
0.57 7.64
0.52 .163 with central neck lymph node dissection. During the
i-ca, mmol/L 0.97
0.07 1.01
0.08 .042 thyroidectomy on the current study, we did careful
POD #10–20
Calcium, mg/dL 8.24
0.69 8.71
0.57 .005
dissection not to injure the parathyroid and inspected
i-ca, mmol/L 1.10
0.09 1.15
0.07 .025 the parathyroid gland thoroughly after dissection.
i-PTH, pg/mL 15.1
9.44 12.2
7.11 .215 When the parathyroid was removed unintentionally or
†
Calcium change, mg/dL 0.36
0.31 0.51
0.53 .041 discolored severely, we reimplanted the parathyroid
†
i-ca change, mmol/L 0.02
0.07 0.08
0.07 .054
gland in the contralateral sternocleidomastoid muscle,
Abbreviations: i-ca, ionized calcium; i-PTH, intact parathyroid hormone; POD, post-
operative day.
and considered the parathyroid ‘‘half removed’’ (Table 2).
*Oral calcium supplements.
†
The number of patients with parathyroid ‘‘half removed’’
Calcium and i-calcium change were checked 6 hours after oral supplementation.
was not different among the 4 groups.
Several studies have shown that routine calcium
normal i-PTH level predicted hypocalcemia after a and vitamin D supplements reduce the incidence and
thyroidectomy with a 71% sensitivity and an 81% severity of symptomatic hypocalcemia.4,5,7,14,15 We
specificity.12 They suggested that this was due to the also confirmed that routine oral calcium and vitamin
short half-life of the parathyroid hormone, and that D supplement therapy given to all patients after total
i-PTH level is markedly diminished if the blood sup- thyroidectomy with central neck lymph node dissec-
ply to the parathyroid glands is blocked. However, it tion can reduce mild to moderate forms of hypocalce-
is not always possible to predict exactly which mia. We noticed that routine oral calcium and
patients will develop postoperative hypocalcemia. vitamin D supplementation before hypocalcemia did
This study was designed to evaluate the preventive not block the necessity for intravenous calcium injec-
role of calcium and vitamin D supplement from post- tions, implying that the meticulous surgical technique
operative hypocalcemia. Because it was hard to pre- to preserve parathyroid glands has a potent effect on
dict who would manifest postoperative hypocalcemic postoperative hypocalcemia.
symptoms, we enrolled all the patients into 1 of the 4 This is the first prospective study to compare the
study groups. In most patients, the duration of calcium effects of 2 different types of vitamin D, cholecalcif-
and vitamin D treatment lasted less than 2 to 3 weeks, erol and calcitriol, on postoperative hypocalcemia pre-
so we did not think this study would be a burden to the vention when administered with oral calcium. The
patients economically. Instead, we performed subgroup roles of vitamin D were not heavily investigated in
analysis for the patients who required additional oral this study but may provide insight into the therapeu-
calcium treatments (Table 5) and evaluated the effec- tic options for the prevention and treatment of
tiveness of 2 different forms of vitamin D. hypocalcemia.
Postoperative i-PTH level is 1 good indicator for Calcitriol is an active form of vitamin D that
the prediction of postoperative hypocalcemia. reaches its maximum serum level 3 to 6 hours after
Unfortunately, it was difficult to treat the patients ingestion. In contrast, cholecalciferol must first be
based on i-PTH level, because a quick i-PTH assay metabolized in the liver and kidneys making its action
was not available in this hospital yet. It took 1 or 2 time 7 to 10 days, thus demanding more time to the
days to get an i-PTH level, so we designed to treat desired effect than is needed with calcitriol. Cholecalcif-
the patients based both on hypocalcemic symptoms erol is supplied as a chewable preparation, which is
and calcium level. In the future, when a quick i-PTH more useful for patients with vocal cord palsy or dys-
assay is available, we will undergo a similar study phagia. Considering the convenience, cholecalciferol can
based on the i-PTH level again. Although there was a be an option for preventing postoperative hypocalcemia.
study indicating that calcium and vitamin D supple- Our current study showed that both cholecalciferol
ments decrease i-PTH levels by inhibiting parathyroid and calcitriol taken with oral calcium have similar
hormone in normal functioning parathyroid glands,13 effects if supplied routinely before the development of
we did not find any harmful effects on i-PTH recovery hypocalcemic symptoms. On the other hand, when
in this study. administered after the onset of hypocalcemic

1270 Calcitriol vs Cholecalciferol on Post-Thyroidectomy Hypocalcemia HEAD & NECK—DOI 10.1002/hed September 2011
symptoms, calcitriol seemed to be more effective in ele-
vating Ca and i-Ca levels than was cholecalciferol. We
also found that calcitriol may have a more immediate
effect on i-Ca changes when given 6 hours after supple-
ment (0.02
0.07 vs 0.08
0.07; p ¼ .056), although
these results were not significant. Calcitriol may be
faster acting for the recovery of laboratory hypocalce-
mia than cholecalciferol.
The weakness of this study is that we did not
investigate the effect of preoperative vitamin D defi-
ciency on the postoperative hypocalcemia. In western
populations, it is increasingly acknowledged that vita-
min D deficiency is relatively prominent. In contrast,
it is not well-evaluated so far in eastern countries.
We expect to study on the correlation between postop-
erative hypocalcemia and vitamin D deficiency
hereafter.
Most patients after total thyroidectomy were able
to quit calcium medications within 2 weeks postopera-
tively, so calcium and vitamin D supplements did not
cause a cost burden to the patients but gave a sense
of stability and alleviated fears of hypocalcemia.
In conclusion, although the number of patients en-
rolled in our study was not sufficient for exact analy-
sis, our data suggest that routine oral calcium and
vitamin D supplement therapies are beneficial to all
patients for preventing mild to moderate, but not
severe symptomatic hypocalcemia after total thyroid-
ectomy and central neck lymph node dissection. We
suggest that cholecalciferol and calcitriol combined
with calcium carbonate have similar roles in the pre-
vention of hypocalcemia when used routinely. If taken
after the onset of hypocalcemia, calcitriol combined
with calcium carbonate may be more effective and
faster for improving postoperative hypocalcemia than
is cholecalciferol combined with calcium carbonate. A
large-scale study will make it possible to define more
exactly the best treatment options for the prevention
of hypocalcemia after total thyroidectomy.
Calcitriol vs Cholecalciferol on Post-Thyroidectomy Hypocalcemia
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HEAD & NECK—DOI 10.1002/hed September 2011 1271