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Guidelines for Management of Post-operative Hypocalcaemia

From British Thyroid Association and Royal College of Physicians Guidelines on Management of Thyroid Cancer 2nd ed, 2007

Chair of Thyroid Cancer Guidelines Update Group: Dr Petros Perros


Management of Hypocalcaemia

  1. Serum calcium should be checked on the day after surgery, and daily until the hypocalcaemia improves147,148 (III, B). A decline in serum calcium concentration in the first 24 hours after surgery is predictive of the need for calcium supplementation.149
  2. If hypocalcaemia develops, calcium supplementation should be started at an initial dose of 500 mg elemental calcium three times daily (IV, C). The dose is adjusted as indicated by the response. Occasionally intravenous calcium gluconate may be required. Mild asymptomatic hypocalcaemia usually does not require treatment, although monitoring is indicated.
  3. If hypocalcaemia does not improve or worsens, introduce alfacalcidol (or calcitriol)(III, B).
  4. Close monitoring of serum calcium is needed to prevent hypercalcaemia (IV, C).
  5. Monitoring of serum calcium should be supervised in the specialist clinic, with the assistance of the GP if appropriate (IV, C).
  6. After total thyroidectomy, 30% of patients will need calcium supplementation with or without alfacalcidol. By 3 months, less than 10% of patients will still require calcium supplementation.150
  7. Hypoparathyroidsm is often transient and a predictor of this is an elevated (or upper normal range) serum parathyroid hormone (PTH) concentration at the time of the occurrence of hypocalcaemia.150 Thus, the majority of patients on calcitriol/alfacalcidol/calcium supplements can have this treatment withdrawn. Supplements should be slowly and gradually reduced and serum calcium monitored every few months until withdrawn and eucalcaemia restored. The combined effects of hypocalcaemia and hypothyroidism are poorly tolerated and calcitriol/alfacalcidol/calcium supplement withdrawal should take place during euthyroidism (IV, C).25
  8. If hypoparathyroidism is permanent, the lowest dose of supplements should be administered to maintain the serum calcium at the lower end of the normal range, while avoiding hypercalciuria. In stable cases annual measurement of serum calcium is recommended (IV, C).

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