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Anything but
pseudopseudohypoparathyroidism
Francis Campbell
Objectives
 Calcium
 Parathyroid
 Revision of disorders of the parathyroid
 Osteoporosis
 Diagnoses
 WHO to Diagnose?
 Treatment
 NICE to Treat?
Calcium
 How many grams of calcium in an average human?
 What percent is in the bones?
 What regulates it?
Calcium
 http://tinyurl.ms/33md
The Parathyroid (s)
 Regulate calcium by secreting PTH
 Acts on PTH1 receptor (bone + kidney) and PTH2 receptor
(CNS, placenta)
 4 (or more)
 100mg
Hyperparathyroidism
 Excess PTH
 Primary
 Secondary
 Tertirary
 Symptoms of high calcium?
 “stones, bones, abdominal groans and psychiatric moans“
Primary Hyperparathyroidism
 High Calcium
 Causes
 Adenoma 97%
 Hyperplasia 2.5%
 Cancer 0.5%
 Treatment
 Surgery
 Bisphosphonates
Secondary Hyperparathyroidism
 Low serum calcium
 Parathyroids go into overdrive
 Resultant gland hypertrophy
 Cause – CKD
 Not enough Vit D
 Treat – underlying cause, replace vit D, phospate binders
 Otherwise…
Tertiary hyperparathyroidism
 Due to prolonged periods of low calcium lvl
 Insensitive
 High calcium
 Treat - surgeons
Osteoporosis
 Define it.
 T score of -2.5 (or greater) on DEXA scanning
Osteoporosis
 Why does it matter?
 £ 1.7 billion / year
 180,000 fractures
 70k hip
 25k vertebral
 41k wrist
 Hip fractures are expensive
Osteoporosis
 How many people in England and Wales?
 A) 1 million
 B) 2 million
 C) 700,000
 What percent of people have it at 50 yrs
 What percent of people have it at 80 yrs
Osteoporosis
 How many people in England and Wales?
 A) 1 million
 B) 2 million
 C) 700,000
 What percent of people have it at 50 yrs
 What percent of people have it at 80 yrs
2%
25%
Osteoporosis
Risk factors for having osteoporosis?
Write them down as quickly as you can
Osteoporosis
Risk factors for having osteoporosis?
Write them down as quickly as you can
Osteoporosis
Risk factors for having osteoporosis?
 History of fractures
 Female sex
 Age
 Family History
 Early untreated Menopause
 Low BMI
 Smoking
 Sedentary lifestyle / immobility
 Alcohol
 Ethnic origins
Osteoporosis
 Secondary causes
 Coeliac disease
 Inflammatory bowel disease
 Chronic liver disease
 Primary hyperparathyroidism
 Hypogonadism
 Thyrotoxicosis
 Chronic renal failure
 Any immunomodulatory condition or treatment
Osteoporosis
 Define it.
 Who do we DXA scan?
Osteoporosis
 Define it.
 Who do we DXA scan?
 Well it depends WHO you ask
 FRAX
 http://www.shef.ac.uk/FRAX/
Osteoporosis
 Define it.
 Who do we DEXA scan?

Well it depends WHO you ask
o FRAX
o http://www.shef.ac.uk/FRAX/
 Or do you ask NICEly?
National Institute for Clinical
Excellence
 NICE – recently updated guidance in Jan 2011 with regards
to fragility fracture in postmenopausal women
 It’s all about risk …
 (different risk to FRAX)
National Institute for Clinical
Excellence
NICE independent risk factors for fracture
•
•
•
Parental hip fracture
EToH of >4 units / day
Rheumatoid arthritis
NICE
NICE independent risk factors for fracture
•
•
•
Parental hip fracture
EToH of >4 units / day
Rheumatoid arthritis
NICE
NICE independent risk factors for fracture
• Parental hip fracture
• EToH of >4 units / day
• Rheumatoid arthritis
NICE indicators of low bone mineral density
•
•
•
•
•
Low BMI <22kg/m
Ankylosing Spondylitis
Crohn’s Disease
Prolonged immobility
Untreated premature menopause
NICE
 So who to DXA?
 (primary prevention)
 Under 65
Indicator of Low BMD AND Independent risk factor for fracture
 Over 70
Indicator of low BMD
 Over 75 and with two clinical risk factors do NOT need DXA scan
Mini Quiz
 Price for one year of treatment (just the pills)
Generic Alendronate 70mg weekly
Non-generic alendronate Fosamax
Risedronate 35mg weekly
Raloxifene (SERM) 60mg daily
Strontium 2g daily
Who got it right?
 Price for one year of treatment (just the pills)
Generic Alendronate 70mg weekly
Non-generic alendronate Fosamax
Risedronate 35mg weekly
Raloxifene (SERM) 60mg daily
Strontium 2g daily
£53.56
£296.40
£264.63
£222.39
£333.71
Does it work?
 Yes
 at a cost.
 What is an ICER and a QALY?
The Cost
 70 yr old women
 T -2.5, no prev fractures
 How much does one QALY cost if I use alendronate (generic)
 £5496
 And if acid suppresion therapy is needed in conjunction
 £13236
The Cost
 The more osteoporotic and older you are
 The more likely you are to fracture
 Therefore you are better value for osteoporotic medication
 BUT
Can I have the best drug doctor?
 I can’t have alendronate can I have another bisphosphonate
Can I have the best drug doctor?
 What about Strontium?
Summary
 Parathyroid
 Disorders
 Osteoporosis
 Diagnoses in a patient without a fracture
 When to treat
 The cost of treatment
Any Questions?