Postoperative hypocalcaemia is usually transient; we present a case report of persistent symptomatic hypocalcaemia following elective thyroid surgery; its challenging pharmaceutical management including the successful use of a novel therapeutic agent. A 56 yr old woman with known type 2 diabetes, morbid obesity (treated with gastric band), and benign intracranial hypertension underwent total thyroidectomy for a multi-nodular goitre, following which she became symptomatic with persistent hypocalcaemia. Acute treatment was with intravenous Calcium Gluconate followed by incremental doses of oral calcium along with stepwise vitamin D supplementation. In-patient stay was protracted and problematic culminating in the need for regular intravenous calcium infusions thrice weekly via a Hickman line along with oral agents (1-Alphacalcidol 6 mcg bd, Calcitriol 6,000 nanogram bd (24 tablets), SandoCal 3 g QDS, Colecalciferol 20,000unit (15 tablets/week), Ergocalciferol 300,000 unit I.M weekly). Despite this our patients calcium ranged from 1.72.01 mmol/L, Vitamin D3 (ranged from <1056 nmol/L) Vitamin D levels were sufficient at over 215 nmol/L , PTH 1.3 (low), Alb 38, Mg 0.6. She also required admission on occasion with long line sepsis warranting removal. On discussion and referral to tertiary centre our patient was commenced on Preotact (Parathyroid Hormone made with recombinant DNA technology) 100 mcg od via subcutaneous injection. This resulted in dramatic improvement in serum calcium (peak 3.02, steady state of 2.42 mmol/L) with significant reduction of oral supplementation to Calcitriol 4tablets/day only. Preotact is usually indicated for the treatment of osteoporosis in postmenopausal women at high risk of fractures current data support continuous treatment for up to 24 months. We have demonstrated a beneficial role of this agent in refractory hypocalcaemia following surgery.
Declaration of interest: There is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.
Funding: No specific grant from any funding agency in the public, commercial or not-for-profit sector.