PRIMARY HYPERPARATHYROIDISM PRIMARY HYPERPARATHYROIDISM. Hyperparathyroidism Etiology. Common Complex Insidious Chronic Global Only cure is surgery

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1 ENDOCRINE DISORDER PRIMARY HYPERPARATHYROIDISM Roseann P. Velez, DNP, FNP Francis J. Velez, MD, FACS Common Complex Insidious Chronic Global Only cure is surgery HYPERPARATHYROIDISM PARATHRYOID GLANDS PRIMARY Abnormality of parathyroid tissue SECONDARY Normal parathyroid function TERTIARY Abnormal parathyroid function Usually 4 Produce PTH hormone Maintain levels of Ca and Ph Hyperparathyroidism Etiology PTH SECRETION Mutation in DNA Increases Ca absorption from GI tract by increasing renal formation of 1,25 dihydroxycholecalciferol from 25- hydroxycholecalciferol 1

2 ABNORMAL GLANDS NORMOCALCEMIC PHTH When Ca decreases, PTH is secreted, increasing Ca through bone resorption and decreasing Ca excretion from kidneys Rule out secondary causes of elevated PTH including medication effects, GFR rate of 60 ml/min; liver disease, and Vit D insufficiency. EXCESS PTH HYPERCALCEMIA Suppresses PTH secretion Directly related to disease duration PTH secretion is decreased when Ca reaches normal levels PRIMARY HYPERPARATHYROIDISM SEROLGIC TESTING Excess production of PTH by glands High PTH in presence of above normal serum Ca Abnormally elevated CA and PTH levels with respect to each other 2

3 CAUSES OF HPTH SYMPTOMS Parathyroid adenoma Parathyroid hyperplasia Parathyroid carcinoma Hypercalcemia caused by inappropriately secreted PTH hormone If Ca rises slowly, pt adapt to changes PRIMARY HPTH VAGUE SYMPTOMS Weakness Ambulatory care hypercalcemia Paresthesia BMD Muscle cramps Fatigue PRIMARY HPTH VAGUE SYMPTOMS Itchy skin Prevalent > 65 (post-menopause) Poor concentration Irritability Depression 3

4 MSK CLINICAL PRESENTATION Asymptomatic vertebral fractures Pathologic fractures Muscle weakness with reflexia Asymptomatic Moans, groans, bones, and stones Severe bone pain CV SYMPTOMS PHYSICAL EXAM HTN Palpitations Shortened Q-T/Prolonged PR Normal in PHPTH since 2-5% can be asymptomatic Bradyarrhythmias SYMPTOMS DIAGNOSIS Dig sensitivity Challenging Insulin resistance/type II DM Early Hyperuricemia Timely referral Gout Medical and surgical approach 4

5 LABORATORY What to do? High Serum Ca Check previous serum Ca If elevated, order a PTH hormone in conjunction with a repeat serum Ca If serum Ca not previously elevated, just repeat the serum Ca CHECK if serum albumin is low Order an ionized Ca or Add.8 to the total Ca for every point that the albumin is below normal SUSPECTING PHTH EXAMPLE Ionized Ca and PTH hormone on same sample of blood Individual Ca and PTH levels fluctuate quickly and the dx rests on the levels in respect to each other. Total Ca level is 7.2 Albumin is 2.5 add.8 for every point the albumin is below normal In this case adding 1.6 (.8 x 2) to the Ca level of 7.2 = Ca level of 8.8 Pt has normocalcemic HPTH disease SERUM ALBUMIN PTH assays Serum albumin and co-morbidities 40% of circulating Ca is bound to albumin If serum albumin is abnormal: ionized Ca levels may be obtained or : {corrected Ca=serum Ca mg/dl+(0.8 x (4- serum albumin)} Help to determine hypercalcemia is parathyroid mediated since up to 20% may be normocalcemic. 5

6 PARATHRYOID HORMONE HYPOPHOSPHATEMIA With hypercalcemia, an intact PTH level of >25 pg/ml is abnormal (normal pg/ml) Biotin supplements may have low PTH Consider medications when interpreting lab data Due to PTH effect on renal system SERUM CREATININE LAB ABNORMALITIES Moderate anemia Renal insufficiency Mg Acid-base Monocolonal gammopathy URINARY CALCIUM RENAL ABNORMALITIES 24 hr urine Ca very low but can be normal or elevated (consider pt dietary Ca intake) Calcium oxylate stones 6

7 WHAT TO DO? NECK IMAGING Order serum Ca in conjunction with albumin or an ionized Ca level REFER Surgical planning IMAGING MEDICAL TREATMENT Plain x-rays BMD lumbar spine B hips distal 1/3 radius Controversy exists re: PHPT with lack of sx GOALS eliminate excess Ca maintain hydration prevent bone loss RENAL IMAGING MEDICAL MONITORING Biannual serum Ca Sonogram if suspicion for nephrolithiasis Annual assessment for S/S Creatinine levels BMD 7

8 PHARMACOLOGIC Calcimemetics Treat but not cure Cinacalcet not for below normal Ca requires close Ca monitoring CV a/e ERT Post menopausal women with low BMD MAY decrease bone resorption does NOT affect serum Ca or PTH levels Raloxefine DIETARY SERUM 25OHD Predicts disease severity Avoid excess Ca intake Low Vit D increased bone turnover, more significant disease, low BMD, more fx MEDICATIONS causing elevated Ca Thiazides Lithium IMPLICATIONS FOR PRIMARY CARE NPS (non surgical candidates) Med reconciliation Avoid volume depletion Limit Ca intake to 1000 mg/day Physical activity units of Vit D daily Adequate water intake 8

9 MEDICAL MGMT Evaluation and mgmt. challenging Mild or less than obvious sx delay dx and treatment Once dx is confirmed, surgery improves QOL and bone health PRIMARY HYPERPARATHYROID Surgical Recommendation Biochemically confirmed PHPTH with overt S/S Asymptomatic pt who meet specific lab or radiology thresholds SEE FLOWCHART SURGICAL REFERRAL PARATHYROID SURGERY Consultation with an experienced parathyroid surgeon can enhance the chance for a cure When there is no specific indication for surgery, parathyroidectomy is an accepted appropriate course of action since surgery is the only cure (Callendar & Udelsman, 2014). GUIDELINES for PARATHYROID SURGERY PARATHYROID SURGERY Safe Four consensus meetings to address asymptomatic PHPT; last meeting 2013 Effective 95% Success Improves QOL when performed by a skilled parathyroid surgeon 9

10 SURGICAL GOAL Remove abnormal PTH tissue and leave pt with normal parathyroid function with minimal surgical complication SURGICAL EXCISION SURGERY Complications Excision of parathyroid adenoma or carcinoma has been shown to rapidly resolve delayed or nonunion after fracture. 1% to 3% recurrent laryngeal nerve damage Permanent hypoparathyroidism RECURRENT DISEASE 5% of Primary hyperparathyroidism Inadequate initial exploration 10

11 CASE STUDY III 79 year old institutionalized female Calcium 13.2 PTH hour urine / sonogram of thyroid Surgery; hyperplasia Total parathyroidectomy with implant CASE STUDY I CASE STUDY IV 52 year old female Routine labs show calcium of 11.3 PTH 182/Calcium Year old admitted from ED with mental status changes CT of head: WNL Calcium level 15.2 Surgery: right upper parathyroid cyst Surgery; left lower parathyroid adenoma CASE STUDY II THANK YOU 72 Year old white male ED with 4 th kidney stone Calcium 12 Calcium 11.8 / PTH 211 Surgery; right lower parathyroid adenoma QUESTIONS? 11