HYPOPARATHYROIDISM

Dr Ranganath N
Professor
Department of Orthopaedics
 Hypoparathyroidism

• Uncommon disorder in which the body

secretes abnormally low levels of parathyroid
hormone.
• The prevalence of hypoparathyroidism in the
United States is estimated to be 24 to
37/100,000 person-years
 ANATOMY
Parathyroid
hormone, or PTH,
is an 84-amino
acid peptide
hormone
PHYSIOLOGY
 Causes of hypoparathyroidism

• Acquired
Hypoparathyroidism
• Autoimmune
Hypoparathyroidism
• Congenital
Hypoparathyroidism
• Idiopathic
Hypoparathyroidism
CAUSES OF HYPOPARATHYROIDISM
• 70% of Hypoparathyroidism is seen in neck
surgeries
• In general, permanent hypoparathyroidism
after neck surgery occurs in between 0.12 and
4.6% of anterior neck operations

• Brandi et al .J Clin Endocrinol Metab, June 2016, 101(6):2273–2283

Parathyroid glands
 Congenital –DIGEORGE SYNDROME

Barakat syndrome (hypoparathyroidism –

sensorineural deafness – renal disease also
called the HDR syndrome),
Kenney-Caffey disease,
Sanjad-Sakati syndrome (hypoparathyroidism
– intellectual disability – dysmorphism),
.
Pseudohypoparathyroidism Type1a
Albright’s hereditary osteodystrophy
 CLINICAL FEATURES

HYPERPHOSPHATEMI TREATMENT
HYPOCALCEMIA A
CALCIUM & VIT D

BRAIN & COGNITIVE CARDIAC

HYPERCALCIURIA,
RENAL

RESPIRATORY RENAL

MUSCULOSKELETAL SOFT TISSUE

CARDIAC SYSTEM
CALCIFICATIONS

ACUTE OR CHRONIC
TRANSIENT OR PERMANENT
 Hypocalcemia

• MEDICAL EMERGENCY -TETANY

ACUTE • SEIZURES,LARYNGEAL SPASM,CARDIAC
ARRHYTHMIAS

• NOT LIFE THEATENING

CHRONIC • PARASTHESIAS,MUSCLE
TWITCHINGS,WEAKNESS,FATIGUE,
• BRAIN FOG
HYPOCALCEMIA
SIGNS AND SYMPTOMS OF CHRONIC
HYPOPARATHYROIDISM
INVESTIGATIONS

“Corrected” Serum Calcium or

IONISED Ca

Corrected calcium = Measured calcium +

0.8 x (4.0 - albumin)

(calcium measured in mg/dL;

albumin measured in g/L)
 INVESTIGATIONS
2. 24 HOUR URINE CALCIUM -
Initially

After treatment-
(Hypercalciuria)
3.IMAGING:
Xrays & CT scan show calcifications in
Basal Ganglion,other soft tissues.

4.BONE DENSITY SCAN (DEXA):

BMD (Z scores),cortical
thickness
• 5.RENAL ULTRASOUND

• 6. GENETIC STUDIES

• 7. Electrocardiogram- Prolonged QcT INTERVAL

• 8. OPTHALMOLOGIC EXAMINATION &Fundoscopy

 TREATMENT
• ACUTE HYPOCALCEMIA:
• 1 OR 2 ampoules of 10% Ca gluconate,containing
90-180 mg of elemental calcium in 50 ml of 5%
dextrose over 10 to 20 mins
• Followed by slower infusion at 0.5 to 1.5
mg/kg/h over an 8 to 10 hr period
Conventional Management of Chronic Hypoparathyroidism

• Dietary calcium and oral calcium supplements

• Active vitamin D or analogs
• Magnesium
• Thiazide diuretics and Low salt diet - to
reduce hypercalciuria
• Phosphate binders and low phosphate diet- to
control hyperphosphatemia
 Six goals of chronic management therapy

1) To prevent signs and symptoms of hypocalcemia;

2) To maintain the serum calcium concentration slightly
below normal (ie, no more than 0.5 mg/dL below
normal) or in the low normal range;
3) To maintain the calcium-phosphate product to below
55 mg /dL (4.4 mmol2 /L2 );
4) To avoid hypercalciuria;
5) To avoid hypercalcemia; and
6) To avoid renal (nephrocalcinosis/nephrolithiasis) and
other extraskeletal calcifications
 Calcium Supplements

• Many formulations available in Market.

• Weight of the total calcium salt not important but clinicians
must be aware of the actual content of elemental calcium.

Calcium carbonate is 40% calcium by weight while calcium

gluconate is only 9%.
1250 mg of calcium carbonate -500 mg of elemental calcium.
A 10cc vial of 10% calcium gluconate has 1 gram of calcium
gluconate but only 93 mg of elemental calcium
 Vit D or Calcitriol
• Large doses of vitamin D (ergocalciferol or
cholecalciferol) – Given earlier caused
Hypercalcemia/ calcium phosphate products
• Current recommendation is to treat with
physiological doses of 1,25-dihydroxyvitamin
D (calcitriol) along with supplemental calcium
• Calcitriol 0.25-2.0 mcg daily
 Caution
• Patients with hypoparathyroidism treated with
calcium and calcitriol must have calcium,
phosphorus, and renal function monitored
periodically. 
• Urine calcium should periodically be measured to
make sure that patients do not develop
hypercalciuria.
• Urine calcium excretion of greater than 200-250
mg/day should alert the physician to reduce the dose
of calcium or vitamin D
 Advancements in treatment
• In 2015 in the United States, the FDA approved Recombinant
human (rh) PTH for the management of hypoparathyroidism
• Amino-terminal fragment of PTH known as teriparatide – WIDELY
USED
• The lowest dose of 50 g is initiated once daily s/c into the thigh.
• Simultaneously, the dose of active vitamin D is reduced by 50%
• The goals of therapy with rhPTH are to minimize or eliminate the
use of active vitamin D, to reduce supplemental calcium to 500
mg daily, and to maintain the serum calcium in the lower range of
normal
 Indications for Considering the Use of rhPTH in
Hypoparathyroidism

• 1. Inadequate control of the serum calcium concentration

• 2. Oral calcium/vitamin D medications required to control the
serum calcium or symptoms that exceed 2.5 g of calcium or 1.5
g of active vitamin D or 3.0 g of the 1- vitamin D analog
• 3. Hypercalciuria, renal stones, nephrocalcinosis, stone risk, or
reduced creatinine clearance or eGFR (60 mL/min)
• 4. Hyperphosphatemia and/or calcium-phosphate product that
exceeds 55 mg2 /dL2 (4.4 mmol2 /L2 )
• 5. A gastrointestinal tract disorder that is associated with
malabsorption
• 6. Reduced quality of life
 Problems

• Black box--- Osteosarcoma in rats

• Very expensive
• Daily injections
 summary
• Although rare,can be seen in post surgical
settings quite often.
• Important to remember these symptoms of
Hypoparathyroidism- most of them complain
• Acute & chronic
• Though treatment is simple,can lead to
longstanding complications
• JUDICIOUS treatment with monitoring
THANK YOU