Hypoparathyroidism in Emergency Medicine Treatment & Management

Updated: Jan 07, 2022
  • Author: Andrew G Park, DO, MPH, FAWM; Chief Editor: Erik D Schraga, MD  more...
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Treatment

Approach Considerations

Acute, symptomatic hypocalcemia is a medical emergency. The main goal of treatment is to restore serum calcium levels to alleviate symptoms of acute hypocalcemia. [45] In the setting of severe symptoms, calcium therapy should be given even if serum levels are only mildly reduced.

Prehospital care should address and stabilize the airways, breathing, and circulation ("the ABCs"), obtain intravenous access, and control seizures with benzodiazepines. Care to prevent long-term complications from hypocalcemia or hypercalcemia [25] should be coordinated with an endocrinologist.

Recombinant human (rh) parathyroid hormone (PTH) (rhPTH[1-84] Natpara) was approved by the FDA as an adjunct to calcium and vitamin D to control hypocalcemia in patients with chronic hypoparathyroidism. Therapy with rhPTH (1-84) is associated with at least a 50% reduction in calcium and active vitamin D requirements as well as maintenance of serum calcium levels. [46] However, there are limited data on the use of PTH in acute hypocalcemia. Cases have been reported in patients following parathyroidectomy, thyroidectomy, and renal transplantation, as well as one hypoparathyroid individual with hypocalcemic cardiomyopathy, but there have been no large-scale studies published on the use of rhPTH (1–84) in acute hypocalcemia of chronic hypoparathyroidism. [2]

Preliminary findings from a phase 2 trial (N = 59) of an investigational long-acting prodrug of PTH(1-34) (TransCon PTH) appear to show a majority of hypoparathyroid patients (91%) treated with this agent achieved independence from oral active vitamin D and decreased calcium supplements (≤500 mg/day), as well as achieved normal serum levels of calcium, phosphate, urinary calcium, and calcium-phosphate product, at week 26. [47]  The drug (15, 18, or 21 microgram per day) was well tolerated; no serious or severe adverse events were associated with treatment regimens. This randomized, double-blind, placebo controlled 4-week trial was followed by a 22-week open-label extension in which PTH(1-34) was titrated (6-60 microgram per day). [47] More data from larger and longer studies are needed to evaluate the safety and efficacy PTH(1-34).

Also see guidelines from the First International Conference on the Management of Hypoparathyroidism for managing hypoparathyroidism [48] ; the European Society of Endocrinology for treatment of chronic hypoparathyroidism in adults [49] ; and the Society for Endocrinology for emegency management of acute hypocalcemia in adults. [50]

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Emergency Department Care

Administer 10 mL of 10% calcium gluconate in 50 mL of 5% dextrose intravenously (IV) over 10 minutes, with electrocardiographic (ECG) monitoring. This can be repeated until the patient is asymptomatic. This process should be followed up with a calcium gluconate infusion.

Treat the underlying cause of the hypoparathyroidism. In postoperative hypo­calcemia and other cases of hypoparathyroidism, this consists of alfacalcidol or calcitriol therapy. Starting doses should be approximately 0.25–0.5 micrograms per day

Treat vitamin D deficiency or hypomagnesemia.

Infuse children with 1.86 mg/kg elemental calcium, IV over 10 minutes, while closely monitoring the pulse rate and QT interval.

Oral therapy consists of calcium carbonate, 1-2 g or more per day, in 3-4 divided doses. This regimen may be appropriate for patients with mildly lowered calcium levels and mild or no symptoms.

Patients with cardiac arrhythmias or who are on digoxin therapy require continuous ECG monitoring during IV calcium replacement. Large-volume calcium infusions should not be used in patients with end-stage renal failure or those who are on dialysis. [50]

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