MANAGEMENT OF         SECONDARYHYPERPARATHYROIDISM  Joy A. Awoniyi, PharmD. Candidate 2012      F l o ri d a A g ri c ul t...
OBJECTIVES To define hyperparathyroidism To discuss the pathophysiology of the disease To distinguish between primary a...
HYPERPARATHYROIDISM Hyperparathyroidism the over -  activity of the parathyroid glands The glands secrete parathyroid  h...
HYPERPARATHYROIDISM       Primary                        Secondary Hyperparathyroidism              Hyperparathyroidism E...
CLINICAL PRESENTATION        Symptoms                        Signs                             Phosphorus levels Bone pa...
COMPLICATIONS       Tertiary hyperthyroidism –        return of calcium to normal        levels without cessation of     ...
TREATMENT Treatment is aimed at correcting calcium to return PTH  levels back to normal Medications   Phosphate Binders...
TREATMENT Dietary Modifications   CKD patients restrict phosphate intake     Recommended maximum of 900mg/day Surgery ...
PATIENT CASE            SECONDARYHYPERPARATHYROIDISM INEND-STAGE RENAL DISEASE
PATIENT BACKGROUND EG is a 54 year old Hispanic male who presented to the  Miami Veterans Affairs medical center on 8/12/...
PATIENT HISTORY Past Medical History     Adult dominant polycystic kidney disease (routine hemodialysis)     Uncontroll...
MEDICATION PROFILE Allergies: Shellfish - Pruritis ADRs: Omeprazole - Thrombocytopenia Home Medications     1. Metoclop...
POST-OP INFORMATION 8/12/11 Laboratory Data 3:32 PM      137   99     38*           Test            Result              ...
POST-OP DAY 1 8/13/11 Laboratory Data 5:02AM                                Test         Result      138    102   49    ...
POST-OP DAY 1            ACTIVE INPATIENT MEDICATIONS1.    Acetaminophen Elixir 650mg/20.3mL PO Q6h PRN2.    Calcium Carbo...
POST-OP DAY 1                      PHYSICAL EXAMINATION     G e n e r al                             P u l m o n ary    ...
POST-OP DAY 1    GENERAL SURGERY ASSESSMENT AND PLAN       Cardiac Function         Assessment – Elevated Blood pressure...
POST-OP DAY 1        NEPHROLOGY ASSESSMENT AND PLAN       Renal Function         Assessment – Patient stable with no sig...
POST-OP DAY 2                PHYSICAL EXAMINATION    Neuro                          Pulmonary     AAO x3               ...
POST-OP DAY 2 8/14/11 Laboratory Data    Calcium – 7.7 mg/dL     (5:49AM) Vital Signs   T max –97.5F   HR – 42-68 BP...
POST-OP DAY 2    GENERAL SURGERY ASSESSMENT AND PLAN       Cardiac Function         Assessment – Blood pressure is eleva...
POST-OP DAY 3 8/15/11 Laboratory Data 5:11AM                                 Test         Result      135   98    53*   ...
POST-OP DAY 3    GENERAL SURGERY ASSESSMENT AND PLAN       Cardiac Function         Assessment – Blood pressure was elev...
POST-OP DAY 4 8/15/11 Laboratory Data 6:00AM      135   91     65*           Test          Result                       ...
DISCHARGE MEDICATION LIST1. Calcium Carbonate 1950mg PO TID2. Cinacalcet 150mg PO daily3. Clonidine TTS-3 Patch 2 topicall...
PATIENT-SPECIFIC              RECOMMENDATIONS The National Kidney foundation published guidelines  with recommendations f...
CASE SUMMARY EG underwent a procedure to remove his parathyroid  gland. After surgery, the patient’s intact PTH level is ...
CASE SUMMARY In patients who undergo dialysis, hypo - and hypercalcaemia  are reported to be associated with increased mo...
REFERENCES KDIGO cl inical practice guidelines for the  diagnosis, ev aluation, prevention and treatment of chronic  kidn...
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Case Presentation: Management of Hyperparathyroidism following Surgery

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Presented by Joy A. Awoniyi at the Miami Veterans Affairs Medical Center in Miami, Florida during my Pharmacy Surgery Elective Rotation.

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Transcript of "Case Presentation: Management of Hyperparathyroidism following Surgery"

  1. 1. MANAGEMENT OF SECONDARYHYPERPARATHYROIDISM Joy A. Awoniyi, PharmD. Candidate 2012 F l o ri d a A g ri c ul t u r a l a n d M e c ha ni ca l Un i v e r si t y Surgery Elective Rotation Preceptor: Dr. Lisa Joseph
  2. 2. OBJECTIVES To define hyperparathyroidism To discuss the pathophysiology of the disease To distinguish between primary and secondary hyperparathyroidism To provide an understanding of the signs and symptoms of hyperparathyroidism To reveal the complications of the disease To discuss the clinical management of hyperparathyroidism To review a patient case involving secondary hyperparathyroidism in end -stage renal disease
  3. 3. HYPERPARATHYROIDISM Hyperparathyroidism the over - activity of the parathyroid glands The glands secrete parathyroid hormone (PTH), which maintains Calcium, Phosphorus, and Vitamin D levels  Regulates release of calcium from the bone  Regulates absorption of calcium in the intestine  Regulates excretion of calcium in the urine In normal functioning individuals, low calcium stimulates the release of PTH to restore the balance
  4. 4. HYPERPARATHYROIDISM Primary Secondary Hyperparathyroidism Hyperparathyroidism Enlargement of one or  Excessive production more glands results in of PTH in response to hyper-secretion of PTH decreased calcium levels Most common cause of hypercalcemia  Caused by conditions that interfere with Causes: Calcium, Phosphate, o  Hyperplasia r Vitamin D Regulation  A benign tumor (adenoma)  Kidney Failure may form on one of the  Malnutrition glands  Vitamin D Deficiency  Parathyroid cancer (rare)
  5. 5. CLINICAL PRESENTATION Symptoms Signs  Phosphorus levels Bone pain or tenderness  Decreased if malabsorption  Increased if kidney failure Muscle weakness or pain  Decreased calcium levels Fatigue Long Bone Fractures  Bone tests determine bone loss or fractures  Bone X-ray Bone fractures  Bone Mineral Density Test Swollen joints  Imaging of the urinary tract and kidneys to show Kidney stones deposits
  6. 6. COMPLICATIONS  Tertiary hyperthyroidism – return of calcium to normal levels without cessation of PTH secretion  Renal Osteodystrophy – bone pain and weakness  Increase fracture risk  Pseudogout  Pancreatitis  Urinary Tract Infection
  7. 7. TREATMENT Treatment is aimed at correcting calcium to return PTH levels back to normal Medications  Phosphate Binders – Reduce phosphate levels in the body  Sevelamer  Lanthanum Carbonate  Vitamin D – enhances Calcium absorption  Calcitriol  Alfacalcidol  Doxercalciferol  Paricalcitol  Cinacalcet - Increases sensitivity of calcium-sensing receptor in the Parathyroid gland
  8. 8. TREATMENT Dietary Modifications  CKD patients restrict phosphate intake  Recommended maximum of 900mg/day Surgery  Kidney Transplant  Parathyroidectomy
  9. 9. PATIENT CASE SECONDARYHYPERPARATHYROIDISM INEND-STAGE RENAL DISEASE
  10. 10. PATIENT BACKGROUND EG is a 54 year old Hispanic male who presented to the Miami Veterans Affairs medical center on 8/12/2011 for a scheduled right hemithyroidectomy. Following surgery the patient developed hypocalcaemia. General Information  Weight – 97.2 kg  Height – 6’3” (75 in)  BMI – 26.84 History of present Illness  Patient was diagnosed with secondary hyperparathyroidism several years ago. Prior to admission, EG had a right inferior parathyroidectomy and experienced recurrent symptoms of hyperparathyroidism.
  11. 11. PATIENT HISTORY Past Medical History  Adult dominant polycystic kidney disease (routine hemodialysis)  Uncontrolled Hypertension  Diabetes Mellitus  Coronary artery disease  GERD Social History  Denies use of tobacco, alcohol, and elicit drugs  Previous smoker, quit 15 years ago Surgical History  Renal allograft removal (8/2010)  Right inferior parathyroidectomy for parathyroid adenoma (2009)  Bilateral native nephrectomy (2006)  Renal Transplant (2000)
  12. 12. MEDICATION PROFILE Allergies: Shellfish - Pruritis ADRs: Omeprazole - Thrombocytopenia Home Medications 1. Metoclopramide 5mg PO Q6hours prn 2. Hydralazine 100mg PO Q8hours 3. Lanthum Carbonate 1000mg PO after meals 4. Lisinopril 40mg PO BID 5. Dialyvite Daily 6. Clonidine 2 patches applied weekly 7. Isosorbide Dinitrate 30mg PO TID 8. Labetalol 600mg PO Q8hours 9. Ranitidine 150mg PO daily 10. Temazepam 30mg PO Qhs 11. Cinacalcet 30mg PO daily 12. Nifedipine PO BID
  13. 13. POST-OP INFORMATION 8/12/11 Laboratory Data 3:32 PM 137 99 38* Test Result 107 Calcium 9.9 mg/dL 5.0 27 7.5* EGFR 8mL/min Vital Signs 9.9  T max –101.7 7.0 107  HR – 48-56 169  BP – 148-169/62-84  RR – 9-14* Laboratory Data 8:40 PM  Calcium – 8.9mg/dL
  14. 14. POST-OP DAY 1 8/13/11 Laboratory Data 5:02AM Test Result 138 102 49 Calcium 8.2 mg/dL(L) 116 Phosphorus 4.9 mg/dL (H) 5.4* 28 8.6* EGFR 7mL/min Vital Signs  T max – 99.2F  HR – 43-58  BP – 112-153/59  RR – 18 Laboratory Data 9:12 PM  Calcium – 8.1mg/dL (L)
  15. 15. POST-OP DAY 1 ACTIVE INPATIENT MEDICATIONS1. Acetaminophen Elixir 650mg/20.3mL PO Q6h PRN2. Calcium Carbonate 1950mg PO TID3. Calcium/Vitamin D 1 tablet daily4. Cinacalcet 150mg PO daily5. Clonidine Patch 2 topically patches weekly6. Heparin Injection 5000U/mL SC Q8hours7. Isosorbide Dinitrate 30mg TID8. Labetalol 600mg PO Q8H9. Lanthum Carbonate 1000mg PO before meals10. Metoclopramide 5mg Q6H PRN11. Morphine Sulfate 1mg Q6H PRN12. Multivitamins 1 Tab PO daily13. Nifedipine SA 60mg PO BID14. Ranitidine 150mg PO daily15. Temazepam 30mg PO Qhs16. Hydralazine 100mg Q8H
  16. 16. POST-OP DAY 1 PHYSICAL EXAMINATION G e n e r al  P u l m o n ary  No Acute Distress  Lungs clear to auscultation  Well-appearing, well nourished bilaterally  Cooperative  A b d o m e n /GI Ne u r o  Abdomen soft, non-tender  AAO x3 and non-distended  No focal deficits  Positive Bowel Sounds C ar d i ac  G e n i t o uri nary  RRR  Patient is Anephric, no urine output  Normal S1 and S2  E x t r e m i tie s Ne c k  2+ Pedal Pulses  Supple, no JVD  No bleeding from surgical site
  17. 17. POST-OP DAY 1 GENERAL SURGERY ASSESSMENT AND PLAN Cardiac Function  Assessment – Elevated Blood pressure overnight. Returning to baseline  Plan –Hemodialysis should help control blood pressure. Advance patient to cardiac diet Electrolyte Disorder  Assessment – Hypocalcaemia  Plan – recheck calcium every 12 hours and prepare for discharge if levels return to acceptable range. Heparin lock IV fluids Pain Management  Plan – Continue Morphine IV
  18. 18. POST-OP DAY 1 NEPHROLOGY ASSESSMENT AND PLAN Renal Function  Assessment – Patient stable with no signs of volume overload.  Plan –Hemodialysis today as scheduled Electrolyte Disorder  Assessment – hyperkalemia, hyperphosphatemia, and hypocalcaemia are likely an effect of ESRD. Hypocalcaemia may be be result of parathyroidectomy  Plan – Continue Calcium replacement and monitor every 12 hours. Recommendations to stop Cinacalcet Mild Anemia  Assessment – Suboptimal status for end stage renal disease  Plan – Follow as an outpatient
  19. 19. POST-OP DAY 2 PHYSICAL EXAMINATION Neuro  Pulmonary  AAO x3  Lungs clear to  No focal deficits auscultation bilaterally Cardiac  A bdomen/GI  RRR  Abdomen soft, non-  Normal S1 and S2 tender and non- distended Neck  Positive Bowel Sounds  Incision clean and dry  No sights of  Genitourinary bleeding, hematoma, o r infection  Patient is Anephric, no urine output Extremities  Hemodialysis removed 3L yesterday  2+ Pedal Pulses
  20. 20. POST-OP DAY 2 8/14/11 Laboratory Data  Calcium – 7.7 mg/dL (5:49AM) Vital Signs  T max –97.5F  HR – 42-68 BPM  BP – 139-186/64-81  RR – 11-29
  21. 21. POST-OP DAY 2 GENERAL SURGERY ASSESSMENT AND PLAN Cardiac Function  Assessment – Blood pressure is elevated. Labetalol held due to bradycardia. Nicardipene drip used for 3 hours and BP now returning to baseline  Plan – Restart PO blood pressure medications. Reduced Labetalol dose from 600mg TID to 300mg TID Electrolyte Disorder  Assessment – Calcium level dropped to 7.7  Plan – Increase supplementation and observe Pain Management  Plan – Continue Morphine IV DVT Prophylaxis  Plan – Continue with Heparin and SCDs
  22. 22. POST-OP DAY 3 8/15/11 Laboratory Data 5:11AM Test Result 135 98 53* Calcium 6.9 mg/dL(L) 137 Phosphorus 4.1 mg/dL 5.6 26 9.1* EGFR 6 mL/min Vital Signs  T max – 98.5F  HR – 42-68 BPM  BP – 141-175/74-83  RR – 16-20 No Changes in Physical Examination
  23. 23. POST-OP DAY 3 GENERAL SURGERY ASSESSMENT AND PLAN Cardiac Function  Assessment – Blood pressure was elevated overnight but is returning to baseline  Plan – Continue PO blood pressure medications. Electrolyte Disorder  Assessment – Calcium level decreased. Patient received only one dose per records  Plan – Increase supplementation and observe. Nephrology suggests IV calcium replacement Pain Management  Plan – Pain controlled with Vicodin DVT Prophylaxis  Plan – Continue with Heparin and bilateral SCDs. Patient needs to ambulate
  24. 24. POST-OP DAY 4 8/15/11 Laboratory Data 6:00AM 135 91 65* Test Result 184 Calcium 8.4 mg/dL 5.0 26 11.2* EGFR 5 mL/min Vital Signs  T max – 98.1F  HR – 52-68 BPM  BP – 151-194/80-94  RR – 20 Patient discharged following dialysis as Calcium levels returned to normal with instructed to follow up with the surgical outpatient clinic in one week
  25. 25. DISCHARGE MEDICATION LIST1. Calcium Carbonate 1950mg PO TID2. Cinacalcet 150mg PO daily3. Clonidine TTS-3 Patch 2 topically patches weekly4. Dialyvite 1 tab daily5. Isosorbide Dinitrate 30mg TID6. Labetalol 600mg PO Q8H7. Lanthum Carbonate 1000mg PO before meals8. Metoclopramide 5mg Q6H PRN9. Nifedipine SA 60mg PO BID10. Ranitidine 150mg PO daily11. Temazepam 30mg PO Qhs12. Hydralazine 100mg Q8H
  26. 26. PATIENT-SPECIFIC RECOMMENDATIONS The National Kidney foundation published guidelines with recommendations for Calcium and phosphate control in patients with CKD For Stage V CKD (CrCl <15mL/min) the guidelines recommend the following  Monitoring  Calcium and Phosphorus every 1-3 months  PTH and alkaline phosphatase ever 3 -6 months  Therapeutic Targets  PTH – 150-300 pg/mL  EG’s most recent level was 303.9pg/mL  Phosphate – 3.5 – 5.5 mg/dL  Calcium – 8.4 – 9.5 mg/dL
  27. 27. CASE SUMMARY EG underwent a procedure to remove his parathyroid gland. After surgery, the patient’s intact PTH level is still elevated, but trending toward the recommended level Serum Intact PTH 1200 1101 1000 800 752.3 600 173.4 400 200 0 303.9 Serum Intact PTH
  28. 28. CASE SUMMARY In patients who undergo dialysis, hypo - and hypercalcaemia are reported to be associated with increased mortality This makes EG’s calcium level a very important monitoring parameter Calcium and Phosphorus Levels 12 10 8 Value (mg/dL) 6 Calcium 4 Phosphorus 2 0
  29. 29. REFERENCES KDIGO cl inical practice guidelines for the diagnosis, ev aluation, prevention and treatment of chronic kidney disease-mineral and bone disorder (CKD -M BD). Ki dney Int 2009; 76(113):S1. Quarles LD, Cronin RE. M anagement of Secondary hyperparathyroidism and mineral metabolism abnormalities in adult predialysis patients with chronic kidney disease. UpToDate Website. Last Updated 2/17/2011. “Hyperparathyroidism”. M edlinePlus by the National I nstitutes of Health. A vailable at: www.nlm.nih.gov/medlineplus/ency/article /001215.htm. A ccessed on 8/16/2011. Utiger RD. Editorial: Treatment of Primary Hyperparathyroidism. N Eng J Med. 1999;341(7): 1301 -1302.

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