{"id":3765,"date":"2022-05-03T11:47:20","date_gmt":"2022-05-03T10:47:20","guid":{"rendered":"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/calciumandbone\/"},"modified":"2023-08-30T09:43:53","modified_gmt":"2023-08-30T08:43:53","slug":"calciumandbone","status":"publish","type":"page","link":"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/endocrinology\/calciumandbone\/","title":{"rendered":"Calcium and Bone"},"content":{"rendered":"\nCalcium and Bone<\/title>\n\n\n\n<h4 class=\"wp-block-heading\">Information <\/h4>\n\n\n\n<p>Patients with primary osteoporosis or with metabolic bone diseases are usually looked after by rheumatology.  The ‘Referral guide’ gives information on who should be referred to endocrinology<\/p>\n\n\n\n<div class=\"wp-block-getwid-tabs\" data-active-tab=\"0\"><ul class=\"wp-block-getwid-tabs__nav-links\"><\/ul>\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Referral Guidelines<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<h4 class=\"wp-block-heading\">Who to refer:<\/h4>\n\n\n\n<p><strong>Patients with biochemical abnormalities of calcium, PTH and vitamin D<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Eg Hypercalcaemia provided the cause is not obviously malignant, renal or gastrointestinal.  A suppressed PTH would suggest a non-endocrine cause of hypercalcaemia. A raised or high\/normal PTH in the context of hypercalcaemia would be suggestive of hyperparathyroidism and should be referred to endocrinology. If the patient is frail\/elderly and you think that they are unlikely to be suitable for referral for parathyroidectomy please consider sending in a referral as \u2018Advice Only\u2019 on SCI Gateway. Where appropriate, we are happy to provide advice without bringing the patient up to clinic.<\/li>\n\n\n\n<li>Patients with hypoparathyroidism should be referred to endocrinology (Low PTH, low Ca, low\/normal 25(OH)D, low 1,25(OH)D, high PO4, normal AlkP \u2013 particularly in patients with history of neck surgery).<\/li>\n\n\n\n<li>Those with severe hypocalcaemia (Ca2+ usually <1.9mmol\/l with muscle twitches, convulsions, Chvostek\u2019s sign, Trousseau\u2019s sign, carpal spasm, papilloedema, prolonged QT interval on ECG) or hypomagnesaemia, who may need iv replacement<\/li>\n\n\n\n<li>Most patients with vitamin D deficiency can be managed in the community (see \u2018Who not to refer\u2019 below).  However, if patients have significant bone pain or do not respond to vitamin D replacement as expected, referral\/discussion with endocrinology would be appropriate.  Patients with low vitamin D, raised PTH and RAISED calcium should also be referred as they may have concomitant primary hyperparathyroidism, in which case vitamin D treatment will probably cause Ca2+ levels to rise further.<\/li>\n\n\n\n<li>Patients with renal failure (eGFR <45) who may need \u2018activated\u2019 vitamin D, or lower doses of vitamin D, should be discussed with the renal team by contacting: <a href=\"mailto:rierenaladvice@luht.scot.nhs.uk\" target=\"_blank\" rel=\"noreferrer noopener\">rierenaladvice@luht.scot.nhs.uk<\/a> Patients with GI disorders who may require high doses or parenteral administration of vitamin D should be discussed with GI.  In general, if you are unsure whether patients meet referral criteria, please use the \u2018Advice only\u2019 option on SCI Gateway<\/li>\n<\/ul>\n\n\n\n<p> <strong>Osteoporosis secondary to endocrine disease e.g.<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Hypogonadism<\/li>\n\n\n\n<li>Hyperparathyroidism<\/li>\n\n\n\n<li>Cushing\u2019s syndrome<\/li>\n\n\n\n<li>Uncontrolled thyrotoxicosis<\/li>\n<\/ul>\n\n\n\n<h4 class=\"wp-block-heading\">Who not to refer:<\/h4>\n\n\n\n<p><strong>Uncomplicated Vitamin D deficiency without other biochemical abnormalities.<\/strong><\/p>\n\n\n\n<p>25(OH) vitamin D level <25 nmol\/l, which is indicative of Vitamin D deficiency\u00a0 If vitamin D deficiency is uncomplicated (eg no other associated biochemical abnormalities or only modest elevations of ALP and PTH), it is usually appropriate to manage the patient in primary care.\u00a0Please see<strong> <\/strong>advice on<strong><a> <\/a><\/strong><a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/vitamin-d\/\"><strong>Vitamin D<\/strong><\/a><strong> <\/strong>in adults. <\/p>\n\n\n\n<p><strong>Hypercalcaemia and known malignancy<\/strong><\/p>\n\n\n\n<p>Refer to oncology<\/p>\n\n\n\n<p><strong>Low\/normal calcium and elevated PTH<\/strong><\/p>\n\n\n\n<p>This is suggestive of secondary hyperparathyroidism in response to low calcium and the cause of low calcium should be sought to guide appropriate referral (eg malabsorption to GI, renal impairment to nephrology). <\/p>\n\n\n\n<p><strong>Osteoporosis with no known underlying endocrine condition<\/strong><\/p>\n\n\n\n<p>Refer to <a href=\"\/refhelp\/guidelines\/Osteoporosis\" target=\"_blank\" rel=\"noreferrer noopener\">rheumatology<\/a><\/p>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Primary Care Management<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<p>It is usually appropriate to manage uncomplicated vitamin D deficiency in primary care.  Please see advice on <a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/vitamin-d\/\">Vitamin D<\/a> in adults.<\/p>\n\n\n\n<p>There is a separate link to guidance for the management of <a href=\"http:\/\/intranet.lothian.scot.nhs.uk\/Directory\/ChildrensServices\/PoliciesGuidelines\/ClinicalPolicies\/Documents\/Vit%20D%20Guideline.pdf\">Vitamin D Deficiency in children and young people<\/a>.<\/p>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Resources and Links<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\"><\/div><\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Calcium and Bone Information Patients with primary osteoporosis or with metabolic bone diseases are usually looked after by rheumatology.  The ‘Referral guide’ gives information on who should be referred to endocrinology<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":3908,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"categories":[125],"class_list":["post-3765","page","type-page","status-publish","hentry","category-calciumandbone"],"publishpress_future_workflow_manual_trigger":{"enabledWorkflows":[]},"rttpg_featured_image_url":null,"rttpg_author":{"display_name":"NHS Lothian","author_link":"https:\/\/apps.nhslothian.scot\/refhelp\/author\/nhs-lothian\/"},"rttpg_comment":0,"rttpg_category":" <a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/category\/endocrinology\/calciumandbone\/\" rel=\"tag\">Calcium and Bone<\/a>","rttpg_excerpt":"Calcium and Bone Information Patients with primary osteoporosis or with metabolic bone diseases are usually looked after by rheumatology.  The ‘Referral guide’ gives information on who should be referred to endocrinology","_links":{"self":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/3765","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/comments?post=3765"}],"version-history":[{"count":5,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/3765\/revisions"}],"predecessor-version":[{"id":14016,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/3765\/revisions\/14016"}],"up":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/3908"}],"wp:attachment":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/media?parent=3765"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/categories?post=3765"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}