Endocrine Abstracts

A 62-year-old lady was being followed up by endocrine surgeons for multi-nodular goitre. She underwent an elective total thyroidectomy in April 2017 and histology confirmed a multinodular goitre with no evidence of malignancy. The patient first developed hypocalcaemia immediately post-operatively and was started on Alfacalcidol 0.25 micrograms daily in addition to Levothyroxine replacement. Unfortunately, the patient was lost to follow-up and re-presented at our endocrine clinic in July 2020 with symptoms and signs indicative of hypocalcaemia i.e. peri-oral paraesthesia, tingling in the hands and positive Chvostek’s and Trousseau’s sign. On taking urgent blood tests, the corrected calcium was 1.77 mmol/l and ECG showed normal sinus rhythm with a prolonged QTC of 488 ms. The patient was then admitted for an intravenous infusion of calcium gluconate while on cardiac monitoring. She received 20 ml 10% calcium gluconate in 50 ml of 5% Dextrose over 10 minutes, after which her symptoms had resolved, then 100 ml of 10% calcium gluconate in 1 Litre 0.9% saline infused at 50 mls/hour. She was concurrently started on Alfacalcidol 0.25 micrograms 8-hourly and Calcium Carbonate 1 g 8-hourly. Unfortunately, despite regular blood tests and up-titration of Alfacalcidol on an out-patient basis, the patient required multiple hospital admissions with symptomatic hypocalcaemia over the span of 2 years. The patient had reached a maximum dose of Calcium Carbonate 1 g 8-hourly and Alfacalcidol 8.5 micrograms daily in October 2022. The decision was taken to start the patient on Natpar (Parathyroid Hormone rDNA) to attempt to prevent the latter. The patient underwent the necessary education on how to administer Natpar subcutaneously and became familiar with the device. She was started on 50 micrograms daily and the Alfacalcidol dose was reduced by 50% as instructed by the drug summary of product characteristics (SmPC). The patient reached a stable level of corrected calcium (ranging between 2.05 and 2.2 mmol/l) on Calcium Carbonate 500 mg 12-hourly, Alfacalcidol 0.5 micrograms daily and Natpar 100 micrograms daily in July 2023 and has since not required further hospital admissions for symptomatic hypocalcaemia or dose adjustments.