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

1. MANAGEMENT OF
SECONDARY
HYPERPARATHYROIDISM
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. 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. 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. 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. 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. 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. 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. TREATMENT
 Dietary Modifications
 CKD patients restrict phosphate intake
 Recommended maximum of 900mg/day
 Surgery
 Kidney Transplant
 Parathyroidectomy

9. PATIENT CASE
SECONDARY
HYPERPARATHYROIDISM IN
END-STAGE RENAL DISEASE

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. 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. 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. 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. 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. POST-OP DAY 1
ACTIVE INPATIENT MEDICATIONS
1. Acetaminophen Elixir 650mg/20.3mL PO Q6h PRN
2. Calcium Carbonate 1950mg PO TID
3. Calcium/Vitamin D 1 tablet daily
4. Cinacalcet 150mg PO daily
5. Clonidine Patch 2 topically patches weekly
6. Heparin Injection 5000U/mL SC Q8hours
7. Isosorbide Dinitrate 30mg TID
8. Labetalol 600mg PO Q8H
9. Lanthum Carbonate 1000mg PO before meals
10. Metoclopramide 5mg Q6H PRN
11. Morphine Sulfate 1mg Q6H PRN
12. Multivitamins 1 Tab PO daily
13. Nifedipine SA 60mg PO BID
14. Ranitidine 150mg PO daily
15. Temazepam 30mg PO Qhs
16. Hydralazine 100mg Q8H

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. 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. 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. 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. 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. 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. 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. 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. 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. DISCHARGE MEDICATION LIST
1. Calcium Carbonate 1950mg PO TID
2. Cinacalcet 150mg PO daily
3. Clonidine TTS-3 Patch 2 topically patches weekly
4. Dialyvite 1 tab daily
5. Isosorbide Dinitrate 30mg TID
6. Labetalol 600mg PO Q8H
7. Lanthum Carbonate 1000mg PO before meals
8. Metoclopramide 5mg Q6H PRN
9. Nifedipine SA 60mg PO BID
10. Ranitidine 150mg PO daily
11. Temazepam 30mg PO Qhs
12. Hydralazine 100mg Q8H

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. 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. 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. 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.