Thread by @LucileFigueres

I duplicate the thread for our english friends @ParathyroidUK !

My patient has hypoparathyroidism: what do I do with it? Short thread for those who could be confronted with this not so simple disease. Feel free to comment/complete.

1/21

Hypoparathyroidism means insufficient serum (blood) PTH concentration to maintain calcemia in the normal range. Diagnosis implies an hypocalcemia state and a normal serum PTH (so inadapted) or low PTH

2/21

Diagnosis requires to correctly assess calcemia (ideally with ionized calcium), completed for interpretation by acid-base status, albuminemia/protidemia. Ionized calcium remains the gold standard 👇

pubmed.ncbi.nlm.nih.gov/31473684/

3/21

After proving hypoparathyroidism, the second step is to assess if it is organic or functional, and here come on the stage by beloved friend : the Magnesium

4/21

There is 3 outcomes for hypomagnesemia : 1/ No Ca/PTH change, 2/PTH is trapped in parathyroid cells, 3/ PTH does not work anymore on its receptor.

5/21

You easily understand that PTH may be low or normal (rarely increased) and it is still hypoparathyroidism. Find the cause of hypomagnesemia (kidney or gut), treat it and control Ca/PTH. More details 👇

pubmed.ncbi.nlm.nih.gov/182417/

6/21

If magnesemia is normal, it is "organic" hypoparathyroidism. Look for neck surgery or radiotherapy, clues for genetic disease (DiGeorge cardiopathy, deafness for HDR syndrom, familial history…)

7/21

Other causes are more rare (auto-immunity, storage disease such as hemochromatosis…) To note, APECED syndrom is a genetic auto-immune disease (gene AIRE mutation)

8/21

How to take care of a patient with hypoparathyroidism:
1-Biology (first in the thread as the most easy to explain, but maybe not the more interesting for a patient point of view)
2-Quality of life (QOL)
3-Complications

9/21

1-Biology: The objective is to maintain the calcemia as normal as possible with the fewer symptoms and without hypercalciuria (risk of kidney stones, nephrocalcinosis, chronic kidney disease)

10/21

25 OH vitamine D and magnesemia should always be in the normal range, frequently with supplementation. Calcium intake (water and/or food containing calcium) will have to be regularly distributed during the day and hopefully remains the same day after day

11/21

Calcium supplements may be needed to maintain calcemia, such as calcitriol (rocaltrol) or alphacalcidiol (un alfa) (as PTH is missing to do the 1 alpha hydroxylation of 25 OH vitamin D)

12/21

Thiazids help to increase calcemia and limit hypercalciuria but only work if salt intake is slow. Normal blood pressure is also required for a better tolerance in patients, rarely in a high blood pressure state.

13/21

Finally, PTH may be prescribed (Forsteo®, PTH 1-34, Natpar® PTH 1-84) subcutaneously. PTH may help for biology but also for QOL. However, only reference centers/doctors may evaluate if it is a good option for a patient.

14/21

PTH has different effects depending on the patients. Patients will still had hypoparathyroidism. Starting PTH is, in my opinion, a medical advice based on the whole medical record but the patient final choice depending on his QOL.

15/21

2- Let’s talk about QOL. Symptomes of hypoparathyroidism are numerous : musculoskeletal pain, headache, depression, fatigue, tetany, tachycardia…So nothing ideal for a peaceful life !

16/21

QOL may also be strongly altered even if calcemia is normal. The problem is the PTH insufficiency, not only the hypocalcemia. By contrast, some patients don’t have symptoms despite severe hypocalcemia.

17/21

Phosphocalcic product has a good correlation with symptoms in this recent review 👇. Thank you for the patients to remind to consider the symptoms even if « calcemia looks perfect »

ncbi.nlm.nih.gov/pmc/articles/P…

18/21

Before assessing biology, ask for the symptoms. These are also what justify treatments adjustement. Reference centers and patients associations as @ParathyroidUK, or @HypoPARAassoc are useful ressources for all

19/21

To end, watch for hypoparathyroidim complications: creatinine and kidney imagery (stones, nephrocalcinosis), ophtalmologist consult every year (early cataract from unknown physiopathology), blood and urine biological follow up.

20/21

Hope I may have helped a little bit for the diffusion of information about hypoparathyroidism. Sorry by advance for all the english misspelling. Feel free to add comments/complete. End of the thread !

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