Endocrine Abstracts

39-year-old female, with a past medical history of Graves Hyperthyroidism, underwent total thyroidectomy 18 years ago, with resultant hypoparathyroidism, hypocalcaemia and hypothyroidism. Her calcium levels are usually in the range of 1.6-1.8 mmol/l, but there are times when it can go to dangerously low levels (range of 1.4-1.15 mmol/l) causing symptoms, sometimes with ECG changes, requiring hospital admissions and IV calcium replacements. There is no parathyroid activity detected when she is hypo calcaemic. Her TSH levels are always high, even on adequate dose of levothyroxine. After careful questioning and assessment, we got to know that the medication compliance seems to be a major concern, but we have never been able to get her to accept that fact. She was very clear that she has been taking all her medications as prescribed, but also mentioned about some episodes of abdominal discomfort, sometimes frequent diarrhoea after taking those, which can sometimes making her to omit doses. Currently she is on AccreteD3(1500/400) 5 tablets three times a day, alfacalcidol 4.5 mg twice daily and levothyroxine 225 mg daily. Her most recent hospital admission was two months ago, when the calcium levels went down to 1.18 mmol/l with symptoms, QT prolongation in ECG, requiring hospital stay, and the calcium levels were 1.82 mmol/l following intravenous calcium infusion. Her levothyroxine absorption test has shown that she was able to absorb levothyroxine when it was given, strongly suggesting that she should be able to absorb her calcium and alfacalcidol. Her recent blood tests showed Serum Calcium (adjusted) of 1.82 mmol/l (post calcium infusion), TSH-12.1 mIU/L, Free T4-13.3 pmol/l. PTH 0.2 pmol/l We are planning for a clinical psychologist review to see if she can benefit from an assessment and to identify extraneous factors contributing to non-compliance. The clinical question is whether there is a role of recombinant parathyroid hormone therapy in this clinical context. There are case reports and studies suggesting the rationale of using these agents to treat post-thyroidectomy hypoparathyroidism, but there are no clear guidelines favouring their use in non-compliance induced severe hypocalcaemia.