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Can treatment for post-thyroidectomy Hypoparathyroidism ever be stopped?

This article introduces the following one which details the Newcastle trial in supplement reduction by Morris & Perros and was presented to the BTA in Oct 2005.

It is well recognized that one or two patients out of every 100 who have a total thyroidectomy will still be hypo parathyroid and require treatment three months after surgery. It is generally felt that this is a permanent condition, but there are some patients whose parathyroid glands recover, sometimes years after surgery. No one seems to know why this happens but doctors involved in thyroid surgery and the treatment of post-surgical Hypoparathyroidism all know patients who have recovered.

To promote recovery of the parathyroid glands and reduce the risk of side effects from too much calcium it is usually recommended that the calcium level is maintained at the low end of the normal range or just below normal if the patient has no symptoms. If calcium levels creep over the middle of the normal range or more, a reduction in treatment is usually recommended to prevent patients becoming symptomatically hypocalcaemic or developing kidney damage. Because of the risk of kidney damage and the fact that replacement with tablets is crude compared to the finely tuned control of calcium metabolism provided by parathyroid glands, treatment with calcium and Alfacalcidol or Calcitriol should only be continued if essential and with regular monitoring.

It seems that patients who develop post-surgical Hypoparathyroidism often can reduce and stop their treatment if the medication is withdrawn very gradually. There has been an attempt in Newcastle upon Tyne, UK1 to actively reduce treatment in patients on long-term treatment for Hypoparathyroidism and this has been successful for about 70% (personal communication from Margaret Morris, March 2006) of those actively managed. The length of time patients had been on treatment did not influence the ability to stop treatment. The reduction in treatment was managed on an individual basis and for some patients the treatment had to be gradually withdrawn over many months. The reduction in treatment was often accompanied by symptoms, which for some patients were unpleasant, but the symptoms settled with time and calcium treatment if required. Some patients found it difficult to interpret their symptoms and would add back treatment unnecessarily which suggests that monitoring of calcium levels might help patients learn to interpret their symptoms more appropriately.

This is good news for patients who have been on treatment for Hypoparathyroidism following thyroidectomy even if it is years since treatment was started. If you wish to consider a reduction in treatment it is important that you discuss it with your doctor, as you will require follow-up and not every patient who appears to fit the description of those involved in the study will be a suitable candidate.

Reference: see article below.

Alfacalcidol and calcium supplement reduction in post-thyroidectomy patients

Margaret Morris, Endocrinology Specialist Nurse; Petros Perros, Consultant Endocrinologist, Endocrine Unit, Freeman Hospital, Newcastle upon Tyne,NE7 7DN.

Hypocalcaemia is common immediately after total thyroidectomy, however permanent Hypoparathyroidism only occurs in 1-2% of cases. Our experience is that Alfacalcidol and calcium supplement therapy is often continued long-term, particularly in patients with a diagnosis of thyroid cancer; this probably relates to attention being paid to other areas of priority after thyroidectomy (radioiodine ablation, challenge scans, interruption and reinstitution of thyroid hormone therapy). Long-term therapy with Alfacalcidol and calcium supplements are associated with risks of renal impairment and should only be continued if essential and with continuing monitoring. We studied 42 patients (31 with thyroid cancer, 11 with benign thyroid disease) recruited over a period of 19 months. Twenty patients were receiving both Alfacalcidol and calcium supplements, 3 patients Alfacalcidol alone and 19 patients calcium supplements alone. At entry mean (SD) values were serum calcium 2.16 (0.13) mmol/l, serum PTH 19.8 (13.7) ng/l (NR10-60), urine calcium/creatinine ratio 0.39 (0.22) (NR 0-0.7). The dose of Alfacalcidol and calcium supplements was gradually reduced. After a median of 7 months (range 1-15) of follow-up, 12 patients were able to stop Alfacalcidol and calcium supplements while maintaining a normal serum corrected calcium and nine patients had the dose of Alfacalcidol reduced. The duration of Alfacalcidol and calcium supplements did not correlate with ability to stop treatment (p>0.05). Most patients, including those who were able to come off Alfacalcidol and calcium supplements, experienced transient hypocalcaemic symptoms following decrements in the dose of supplements. In conclusion, Alfacalcidol and calcium supplements can be reduced if not stopped while maintaining eucalcaemia, in many patients with post-thyroidectomy hypocalcaemia, though transient symptoms of hypocalcaemia are experienced by most. Counseling and support in a specialist nurse clinic setting provides useful support and the necessary monitoring required for a successful outcome.

(Presented at the British Thyroid Association meeting October 2005).

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