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Thyroid Diseases

ENT Surgeon and Thyroidectomy/Parathyroidecto

04/06/2010

Question:

My thyroid was completely removed (no cancer) and about 2 1/2 parathyroid glands. The surgeon had trouble locating the parathyroid adenoma.

I am presently on 100 mcg. Synthroid. (Was on 112 mcg. and having insomnia. My surgery was January 8. I weigh 125 lbs. and am 72 years old. Current level for T4 is 1.2 and TSH .9

How often should I have the levels checked?

My calcium levels are low: blood level of calcium is 8.3 and ionized calcium is 1.05. PTH is 14.6 I am taking 600mg. calcium citrate 3 times a day, and .25mcg Calcitriol 2 times a day.

How much oral calcium can be taken in a 24-hour period? I am concerned about kidney stones. Is calcium citrate a "safer" route than calcium carbonate--particularly in the elderly? Is it more absorbable? In your experience, how long could it take for the remaining parathyroid glands to become reactivated?

Since I went from having too much calcium and high parathyroid levels prior to surgery to the opposite scenario, what`s happening to my bones now. I do have osteoporosis. Could the calcium supplementation I`m taking now be going more to the bones than into the bloodstream?

I would very much appreciate any insight and information you could give me.

Answer:

How often should I have the levels checked?

I don't have the normal limits for this particular TSH assay, but it appears that your thyroid levels are normal on your current dose of thyroid hormone. I would want to see what your thyroid levels were like after you had been on the new dose of thyroid hormone for a good 2 or 3 months. If the levels were normal at that time then I would say you should just get them checked once a year. Thyroid hormone needs can vary with time, but they usually change very slowly.

How much oral calcium can be taken in a 24-hour period?

The dose that you are on is a perfectly reasonable dose for a person who has problems with low calcium in the blood. I have had patients who required as many as 24+ calcium tablets daily as their “hungry bones” (see below) sucked up the calcium. In patients who develop symptoms of low calcium as described above, the amount and duration of calcium therapy can be guided both by checking blood levels (initially as often as once or twice weekly), and by the patient's adjusting their own calcium dose to be just enough to prevent symptoms.

I am concerned about kidney stones. Is calcium citrate a "safer" route than calcium carbonate--particularly in the elderly? Is it more absorbable?

It might be reasonable for your doctor to check a 24-hour urine calcium level to be sure you aren't flushing a large amount of calcium through your blood into the urine. However, having said that, there is no published evidence that increasing the urinary calcium with calcium pills and calcitriol increases your risk of developing kidney stones, so your doctor isn't really doing anything wrong if she hasn't checked this. Calcium citrate isn't particularly "safer" than calcium carbonate, but it can be better absorbed. Calcium carbonate requires acid in the stomach to be fully absorbed. Many older individuals don't make very much acid in the stomach and so calcium citrate may be better absorbed than calcium carbonate. Also, calcium citrate may be better absorbed if patients are taking pills to decrease stomach acid, like Zantac or Prilosec or Nexium. Another advantage of calcium citrate is that citrate itself inhibits kidney stone formation – although, as mentioned above, stone formation should not particularly be an issue in your postoperative period.

In your experience, how long could it take for the remaining parathyroid glands to become reactivated?

It could take months to years, and it is possible that the condition is permanent.

Since I went from having too much calcium and high parathyroid levels prior to surgery to the opposite scenario, what’s happening to my bones now. I do have osteoporosis. Could the calcium supplementation I’m taking now be going more to the bones than into the bloodstream?

High levels of PTH cause bone reabsorption, meaning that microscopic areas of bone dissolve. This causes calcium to be released from the bone into the bloodstream (resulting in the high calcium levels) and into the urine (sometimes resulting in kidney stones). After removal of a parathyroid adenoma, PTH levels plummet, and the opposite events occur: the bones, which were previously dissolving, now begin to rebuild and to increase their calcium content. A condition called "hungry bone syndrome" can develop, in which calcium is avidly taken up from the blood into the re-forming bone, and blood levels of calcium then become low, sometimes low enough that patients develop symptoms such as muscle spasms or a "pins and needles" sensation in the fingers or around the mouth. The treatment for hungry bone syndrome is simply to supply the body with lots of calcium, as well as vitamin D (in the form of calcitriol), allowing bones to rebuild. Hungry bone syndrome may last for weeks to months, depending on how high the PTH levels were before surgery, and how long the PTH levels were high (in some patients, years).

However, your blood calcium levels aren't low just because all the calcium is going into your bones. They are low because of the damage to your parathyroid glands. As mentioned above, it could take months to years for your remaining parathyroid glands to become reactivated. In the meantime, you will need to continue taking the calcium and calcitriol.

For more information:

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Response by:

Mildred   Lam, MD Mildred Lam, MD
Associate Professor of Medicine
School of Medicine
Case Western Reserve University

Thomas A Murphy, MD, FACP, FACE Thomas A Murphy, MD, FACP, FACE
Associate Professor of Medicine
School of Medicine
Case Western Reserve University