scholarly journals Use of parathyroid hormone analog (Teriparatide) in patients with chronic hypoparathyroidism after total thyroidectomy: a case report

2020 ◽  
Vol 4 (2) ◽  
pp. 29-35
Author(s):  
Avinash Rai ◽  
P Karki ◽  
D Paudel ◽  
R Maskey
Keyword(s):  
Vitamin D ◽  
Thyroid Cancer ◽  
Parathyroid Hormone ◽  
Total Thyroidectomy ◽  
Standard Treatment ◽  
Hormone Analog ◽  
Postoperative Hypoparathyroidism ◽  
Treatment Refractory ◽  
Chronic Hypoparathyroidism ◽  
Intravenous Calcium

Background: Hypoparathyroidism and hypocalcemia is a common postoperative complication, after total thyroidectomy due to thyroid cancer. Standard treatment with supplementation of calcium and vitamin D analogs, usually treat this condition. In some patients, hypoparathyroidism is refractory to standard treatment plus intermittent calcium infusions with persistent low serum calcium levels and associated clinical complications. Attempts have been made to add recombinant human parathormone (rhPTH) to the treatment schedule. To our knowledge, this is the first time that we encounter a patient suffering from treatment-refractory postsurgical hypoparathyroidism who was treated with teriparatide. Case presentation: Male (31 years) with postoperative hypoparathyroidism, after total thyroidectomy due to papillary thyroid cancer, several weeks after the surgery still required intermittent intravenous calcium infusions because of tetany symptoms. He had persistent hypocalcemia despite oral treatment with up to 1 ug calcitriol and 4 g calcium per day necessitating additional intravenous administration of calcium gluconate intermittently. This time, Teriparatide treatment was introduced at once daily 50 micrograms (mcg) subcutaneous injection, while doses of calcium and calcitriol were gradually decreased depending on the response of serum total and ionized calcium taken periodically, which resulted in total resolution of hypocalcemia symptoms and the achievement and maintenance of laboratory normocalcaemia in just 5 days. Conclusion: Treatment refractory chronic hypoparathyroidism may be seen in some cases after total thyroidectomy. Furthermore, the use of recombinant human parathyroid hormone analog (Teriparatide) allows for the control of recurrent hypocalcemia reducing the daily dosage of calcium and vitamin D. Finally, regular intravenous calcium administration was no more needed.

scholarly journals Vitamin D Insufficiency Predicts Susceptibility of Parathyroid Hormone Reduction after Total Thyroidectomy in Thyroid Cancer Patients

2021 ◽  
Vol 2021 ◽  
pp. 1-7
Author(s):  
Yan Zhang ◽  
Weihui Zheng ◽  
Yuanyuan Huang ◽  
Chao Chen
Keyword(s):  
Vitamin D ◽  
Thyroid Cancer ◽  
Parathyroid Hormone ◽  
Total Thyroidectomy ◽  
Independent Predictor ◽  
Laboratory Data ◽  
Vitamin D Insufficiency ◽  
Reduction Ratio ◽  
Postoperative Hypoparathyroidism ◽  
Significant Difference

Objective. Given its role in the regulation of calcium and PTH levels, vitamin D was presumed as a potential predictor of postoperative hypoparathyroidism. However, the reports about their association were controversial. This study aims to reveal the relationship between preoperative vitamin D and postoperative parathyroid hormone (PTH). Methods. A total of 242 papillary thyroid cancer (PTC) patients who underwent total thyroidectomy (TT) during the period from June 2016 to December 2017 at our hospital were enrolled. Patients were divided into two groups, HypoP and Non-HypoP groups, based on postoperative PTH < 15.0 or ≥15.0 pg/mL, and ΔPTH50+ and ΔPTH50− groups, based on postoperative PTH reduction ratio ≥ 50% or <50%. Clinicopathological features and laboratory data were compared between two sets of groups. Results. Preoperative PTH level was lower in the HypoP group than in the Non-HypoP group (42.83 vs. 47.52 pg/mL, p = 0.018 ). No significant difference of vitamin D insufficiency was found between the HypoP and Non-HypoP groups (80.8% vs. 74.1%, p = 0.226 ). The rate of vitamin D insufficiency was higher in the ΔPTH50+ group than in the ΔPTH50− group (82.6% vs. 68.4%, p = 0.010 ). By multivariate logistic regression analysis, vitamin D insufficiency was an independent predictor of postoperative PTH reduction ratio ≥ 50% (OR = 2.2, p = 0.017 ). Conclusion. Vitamin D insufficiency is not associated with postoperative PTH in PTC patients undergoing TT. However, vitamin D insufficiency is an independent predictor of postoperative PTH reduction ratio.

scholarly journals CLINICAL CASE OF TERIPARATIDE USE FOR THE TREATMENT OF POSTOPERATIVE HYPOPARATHYROIDISM WITH UNCONTROLLED HYPOCALCEMIA COMBINED WITH SEVERE OSTEOPOROSIS

2016 ◽  
Vol 19 (3) ◽  
pp. 37-40 ◽  
Author(s):  
T A Grebennikova ◽  
I I Larina ◽  
Zh E Belaya ◽  
L Y Rozhinskaya
Keyword(s):  
Vitamin D ◽  
Parathyroid Hormone ◽  
Surgical Procedures ◽  
Clinical Case ◽  
Standard Treatment ◽  
Clinical Presentation ◽  
Severe Osteoporosis ◽  
Oral Calcium ◽  
Postoperative Hypoparathyroidism ◽  
Severe Clinical Presentation

The development of postsurgical hypoparathyroidism is the most frequent complication of thyroidectomy and radical surgical procedures on the neck. Hypoparathyroidism is a disorder characterized by hypocalcemia, parathyroid hormone (PTH) deficiency, and abnormal bone remodeling. Standard treatment of hypoparathyroidism consists of oral calcium and active forms of vitamin D. However, some patients fail to achieve the normalization of calcium levels with this therapy. We present a clinical case of postsurgical hypoparathyroidism with severe clinical presentation of hypocalcaemia treated with recombinant human PTH 1-34 - teriparatide.

scholarly journals A Prospective Study of Vitamin D Supplement in Thyroidectomy Patients Based on Relative Decline of Parathyroid Hormone

2021 ◽  
Vol 12 ◽  
Author(s):  
Qing Hao ◽  
Yun Qin ◽  
Wanjun Zhao ◽  
Lingyun Zhang ◽  
Han Luo
Keyword(s):  
Vitamin D ◽  
Parathyroid Hormone ◽  
High Risk ◽  
Prospective Study ◽  
Oral Calcium ◽  
Group A ◽  
Relative Decline ◽  
A Prospective Study ◽  
Vitamin D Supplement ◽  
Intravenous Calcium

Background: In postthyroidectomy patients, hypocalcemia is the most common complication to prolong hospital stay and decrease patients’ satisfaction. Based on current evidence, it is recommended to supply vitamin D to patients with high risk of developing hypocalcemia. However, how to stratify the risk of patients remains challenging.Aim: We conducted a prospective study to evaluate the effect of vitamin D supplement (calcitriol) on high-risk hypocalcemia patients based on relative decline of parathyroid hormone (RDP).Method: RDP was calculated by the difference between preoperative and postoperative first-day PTH divided by preoperative PTH and presented as percentage. Patients who underwent total thyroidectomy in addition to bilateral central compartment dissection were enrolled prospectively and were divided into two cohorts: Cohort I: patients with RDP ≤70% and Cohort II: patients with RDP &gt;70%. Patients in Cohort I were then randomly assigned to Group A or B, and patients in Cohort II were randomly assigned to Group C or D. All groups received oral calcium, and patients in Groups B and D also received calcitriol. All patients were followed for one year. In the study, standard procedure dictates that only oral calcium is given to patients whose RDP ≤70% and that oral calcium and calcitriol are given to patients whose RDP &gt;70%. Therefore, Cohort I Group A and Cohort II Group D are controls in this study.Results: The incidence of clinical hypocalcemia in Groups A and D (the controls) was 11.0% (10/91), and 17.6% (16/91) required additional intravenous calcium. Of note, no patients developed permanent hypocalcemia. Furthermore, calcitriol supplement did not have significant impact on clinical outcomes between Group A and B in Cohort I. By contrast, calcitriol supplement distinctly improved clinical outcome by comparing Groups C and D (Cohort II), as marked by clinical hypocalcemia, need of requiring intravenous calcium, and long-termed decreased levels of PTH.Conclusion: Supplying calcitriol based on RDP cutoff of 70% may be a wise practice in thyroidectomy patients, and RDP 70% may be a useful predictor to stratify high-risk patients.

Management of Completion and Total Thyroidectomy Patients Based on 1-Hour Postoperative Parathyroid Hormone

2016 ◽  
Vol 82 (10) ◽  
pp. 881-884
Author(s):  
Joshua Park ◽  
Ethan Frank ◽  
Alfred Simental ◽  
Sara Yang ◽  
Christopher Vuong ◽  
...  
Keyword(s):  
Vitamin D ◽  
Parathyroid Hormone ◽  
Total Thyroidectomy ◽  
Early Discharge ◽  
Vitamin D Supplementation ◽  
Initial Management ◽  
Management Protocol ◽  
Symptomatic Hypocalcemia ◽  
Risk Patients ◽  
One Year

After thyroid surgery, protocols based on postoperative parathyroid hormone (PTH) levels may prevent symptoms of hypocalcemia, while avoiding unnecessary prophylactic calcium and/or vitamin D supplementation. We examined the value of an initial management protocol based solely on a single PTH level measured one hour after completion or total thyroidectomy to prevent symptomatic hypocalcemia by conducting a retrospective review of 697 consecutive patients treated from July 2003 to April 2015. The proportion of patients who developed symptomatic hypocalcemia was similar between those treated before (n = 155) and after (n = 542) implementation of this 1-hour PTH protocol (16.8% vs 15.9%; P = 0.786). Those in the 1-hour PTH groups had lower overnight observation rates (97.4% vs 53.7%; P < 0.001) and length of stay (1.98 ± 2.61 vs 0.89 ± 1.87 days; P < 0.001), and required less calcium (3.9% vs 0.8%; P = 0.015) and vitamin D (2.6% vs 0%; P = 0.002) supplementation one year after surgery. Less than 1 per cent of patients discharged on the day of surgery in accordance with the 1-hour PTH guidelines returned to the emergency room for symptomatic hypocalcemia; none experienced significant morbidity. This protocol facilitates early discharge of low-risk patients and results in a similar or improved postoperative course compared with traditional overnight observation.

scholarly journals Measurement of serum intact parathyroid hormone (iPTH) at the end of total thyroidectomy: A reliable parameter for hypocalcemia?

2021 ◽  
Vol 108 (Supplement_4) ◽  
Author(s):  
A Lalos ◽  
K Linke ◽  
M von Flüe ◽  
B Kern
Keyword(s):  
Parathyroid Hormone ◽  
Total Thyroidectomy ◽  
Clinical Symptoms ◽  
Parathyroid Tissue ◽  
Postoperative Management ◽  
Parathyroid Glands ◽  
Intact Parathyroid Hormone ◽  
Postoperative Hypoparathyroidism ◽  
Symptomatic Hypocalcemia ◽  
The Mean

Abstract Objective Total thyroidectomy represents the gold standard surgical procedure for patients with malignant thyroid disease. Over the past decades, the total thyroidectomy gradually replaced the subtotal thyroidectomy for benign thyroid disorders as well. Postoperative hypocalcemia remains the most frequent complication. The close proximity of parathyroid glands to the thyroid capsule leads often to devascularization or adventitious removal of parathyroid tissue. Clinical symptoms like paresthesia, tingling, muscle cramps or seizures often occur. Combined measurement of intact parathyroid hormone (iPTH) and calcium after the operation are used worldwide to predict postoperative hypoparathyroidism. The purpose of this study was to find out the incidence of decreased iPTH at the end of surgery and its reliability in predicting hypocalcemia. Methods We performed a retrospective analysis of 534 patients who underwent total thyroidectomy at our institution between 2000 and 2019. Medical records were reviewed to analyze the patient characteristics, indication of the procedure, laboratory and histological results, postoperative management and complications. The iPTH was measured before and at the end of the surgery, while the calcium was measured at the first postoperative day. The iPTH assay at our hospital has a normal range between 15.0 and 80.0 pg/ml. Meanwhile hypocalcemia was defined as a calcium measurement &lt; 2.2 mmol/l. Results The mean age of the patients was 55.34 years. The female to male ratio was 4.6:1. The mean preoperative iPTH of our cohort was 48.35 pg/ml, while the postoperative iPTH was 31.74 pg/ml, indicating a mean reduction of 35.75%. A total of 174 patients (32.6%) had a iPTH &lt; 15.0 pg/ml at the end of the surgery, indicating a reduction of 75.6%. 22 of these 174 patients (12.6%) developed clinical symptoms of hypocalcemia. In contrast only 3 patients (0.08%) with normal iPTH developed symptoms. Whole parathyroid glands were identified in 95/534 (17.8%), whereas from the 174 patients with iPTH &lt; 15.0 pg/ml, 56 (32.2%) had at least one parathyroid gland in the operative specimens. Conclusion Measurement of iPTH at the end of total thyroidectomy is a good predictor to detect patient who are at risk for developing symptomatic hypocalcemia and calcium substitution can be started at the same day. A normal iPTH almost excludes symptomatic hypocalcemia.

Relationship of Vitamin D Deficiency and Intraoperative Parathyroid Hormone Elevation in Completion and Total Thyroidectomy

2019 ◽  
Vol 160 (4) ◽  
pp. 612-615 ◽  
Author(s):  
Bradley R. Lawson ◽  
Andrew M. Hinson ◽  
Jacob C. Lucas ◽  
Donald L. Bodenner ◽  
Brendan C. Stack
Keyword(s):  
Vitamin D ◽  
Parathyroid Hormone ◽  
Secondary Hyperparathyroidism ◽  
Total Thyroidectomy ◽  
Vitamin D Deficiency ◽  
Case Series ◽  
Hormone Levels ◽  
Parathyroid Autotransplantation ◽  
Vitamin D Levels ◽  
Intraoperative Parathyroid Hormone

Objective To quantify how frequently intraoperative parathyroid hormone levels increase during thyroid surgery and to explore a possible relationship between secondary hyperparathyroidism due to vitamin D deficiency and elevation in intraoperative parathyroid hormone. Study Design Case series with chart review. Setting Tertiary academic center. Subjects and Methods A total of 428 consecutive patients undergoing completion and total thyroidectomy by the senior author over a 7-year period were included for analysis. All patients had baseline and postexcision intraoperative parathyroid hormone levels as well as vitamin D levels from the same laboratory. Institute of Medicine criteria were employed for vitamin D stratification (>30, normal; 20-29.9, insufficient; <20, deficient) . Other data analyzed include sex, age, neck dissection status, and parathyroid autotransplantation. Results A total of 118 patients (27.6%) had an intraoperative parathyroid hormone elevation above baseline. Patients with vitamin D deficiency were significantly more likely to experience hormone elevation ( P = .04). When parathyroid hormone rose, it did so by a mean 32.1 pg/mL. Patients with vitamin D deficiency demonstrated significantly larger hormone increases ( P = .03). Conclusion Elevation in intraoperative parathyroid hormone levels above baseline after completion and total thyroidectomy occurs in over one-fourth of cases and is significantly associated with vitamin D deficiency. This study is the first to report this observation. We hypothesize that vitamin D deficiency in these patients may create a subclinical secondary hyperparathyroidism that leads to intraoperative parathyroid hormone elevation when the glands are manipulated. Additional studies will be needed to explore this physiologic mechanism and its clinical significance.

scholarly journals Parathyroid hormone: an early predictor of symptomatic hypocalcemia after total thyroidectomy

2012 ◽  
Vol 56 (3) ◽  
pp. 168-172 ◽  
Author(s):  
Felipe Augusto Brasileiro Vanderlei ◽  
Jose Gilberto Henriques Vieira ◽  
Flavio Carneiro Hojaij ◽  
Onivaldo Cervantes ◽  
Ilda Sizue Kunii ◽  
...  
Keyword(s):  
Vitamin D ◽  
Parathyroid Hormone ◽  
Total Thyroidectomy ◽  
Serum Calcium ◽  
Vitamin D Supplementation ◽  
Cutoff Value ◽  
Increased Risk ◽  
Symptomatic Hypocalcemia ◽  
Early Predictor ◽  
Selection Of

OBJECTIVE: The purpose of this study was to evaluate if the measurement of peri-operative parathyroid hormone (PTH) is able to identify patients with increased risk of developing symptoms of hypocalcemia. SUBJECTS AND METHODS: Forty patients who underwent total thyroidectomy were studied prospectively. Ionized serum calcium and PTH were measured after induction of anesthesia, one hour (PTH1) and one day after surgery (PTH24). Patients were evaluated for symptoms of hypocalcemia and treated with calcium and vitamin D supplementation as necessary. RESULTS: Symptomatic hypocalcemia developed in 16 patients. Symptomatic patients had significant lower PTH1 and greater drops in PTH levels. The selection of 12.1 ng/L as PTH1 level cutoff level divided patients with and without symptoms with 93.7% sensitivity and 91.6% specificity. The selection of 73.5% as the cutoff value for PTH decrease resulted in 91.6% sensitivity and 87.5% specificity. CONCLUSION: PTH1 levels and the drop in PTH levels are reliable predictors of developing symptomatic hypocalcemia after total thyroidectomy.

Endocrine Complications of Surgical Treatment of Thyroid Cancer: An Update

2017 ◽  
Vol 125 (08) ◽  
pp. 497-505 ◽  
Author(s):  
Pedro Iglesias ◽  
Juan Díez
Keyword(s):  
Risk Factors ◽  
Vitamin D ◽  
Thyroid Cancer ◽  
Surgical Treatment ◽  
Surgical Technique ◽  
Vitamin D Supplementation ◽  
Response To Therapy ◽  
Postoperative Hypoparathyroidism ◽  
Surgeon Experience ◽  
Endocrine Complications

AbstractPostoperative hypoparathyroidism (HypoPT) and hypothyroidism (HypoT) are the main endocrine complications after the surgical treatment for thyroid cancer. Postsurgical HypoPT can be transient, protracted or permanent. Its frequency varies according to the underlying cervical pathology, surgical technique, and mainly the experience of the surgeon. Risk factors for HypoPT include aggressiveness of the tumor, extent of surgery, the presence of parathyroid gland in the pathologic specimen, and surgeon experience. Clinical manifestations of postsurgical HypoPT can be acute or chronic. An adequate surgical technique that minimizes trauma and preserve the vascularization of the parathyroid glands is the better procedure to reduce the risk of postoperative HypoPT. Acute hypocalcemia may be managed with intravenous or oral calcium supplements, according to the level of serum calcium and the presence of signs and symptoms. Patients with permanent HypoPT require lifelong calcium and vitamin D supplementation. Calcitriol is the vitamin D metabolite of preference because of its high activity and short half-life. Both PTH (1–34) and intact PTH (1–84) have demonstrated to be attractive options in hypoparathyroid patients who cannot maintain stable serum and urinary calcium levels with calcium and vitamin D supplementation. However, the long-term safety of these preparations has not been established. Postsurgical HypoT is an unavoidable consequence of total or near-total thyroidectomy for thyroid cancer. Replacement and suppressive therapy are necessary in these patients. Thyroid hormone suppression therapy has shown to be accompanied by a decreased risk of disease progression and recurrence; however, it may also be associated with increased risk of dysrhythmia and loss of bone mass. Therefore, the intensity of TSH suppression must be established in a personalized way after balancing risk and benefits, according to the severity of the thyroid cancer, the response to therapy, and the individual risk factors for adverse events.

scholarly journals Association between number of parathyroid glands identified during total thyroidectomy and functional parathyroid preservation

2021 ◽  
Author(s):  
Fiona Riordan ◽  
Matthew S. Murphy ◽  
Linda Feeley ◽  
Patrick Sheahan
Keyword(s):  
Vitamin D ◽  
Multivariate Analysis ◽  
Total Thyroidectomy ◽  
Parathyroid Glands ◽  
Graves Disease ◽  
Permanent Hypoparathyroidism ◽  
Academic Teaching ◽  
Postoperative Hypoparathyroidism ◽  
Academic Teaching Hospital ◽  
Systematic Identification

Abstract Purpose Systematic identification of all 4 parathyroid glands has been recommended during total thyroidectomy (TT); however, it is unclear whether this strategy necessarily translates into optimized functional parathyroid preservation. We wished to investigate the association between number of parathyroids identified intraoperatively during TT, and incidence of incidental parathyroidectomy, and postoperative hypoparathyroidism. Methods Retrospective review of prospectively maintained database of 511 consecutive patients undergoing TT at an academic teaching hospital. The association between number of parathyroid glands identified intraoperatively and incidence of biochemical hypocalcaemia (defined as any calcium < 2 mmol/L n first 48 h after surgery), symptomatic hypocalcaemia; permanent hypoparathyroidism (defined as any hypocalcaemia or need for calcium or vitamin D > 6 months after surgery), and incidental parathyroidectomy, was investigated. The association between number of parathyroid glands visualized and postoperative parathyroid hormone (PTH) levels was investigated in a subset of 454 patients. Results Patients in whom a greater number of parathyroids had been identified had a significantly higher incidence of biochemical and symptomatic hypocalcaemia, and significantly lower postoperative PTH levels, than patients with fewer glands identified. There were no significant differences in incidence of permanent hypoparathyroidism or incidental parathyroidectomy. On multivariate analysis, malignancy, Graves disease, and identification of 3–4 parathyroids were independent predictors of biochemical hypocalcaemia. For symptomatic hypocalcaemia, identification of 2–4 parathyroids, and identification of 3–4 parathyroids, were significant. Conclusions Systematic identification of as many parathyroid glands as possible during TT is not necessary for functional parathyroid preservation.

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