TYPE 1 TYPE 2 - am.aace. 1 TYPE 2 Intuitive Analytic Fast Deliberate Experiential Rational ......

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Transcript of TYPE 1 TYPE 2 - am.aace. 1 TYPE 2 Intuitive Analytic Fast Deliberate Experiential Rational ......

  • TYPE 1 TYPE 2

    Intuitive Analytic

    Fast Deliberate

    Experiential Rational

    Pattern Recognition Careful Analysis

    Matching Against Illness Scripts Consider Wider differential

  • Hypercalcemia: Background

    Hypercalcemia: Differential PTH Primary Hyperparathyroidism majority in outpatients Tertiary hyperparathyroidism Familial hypocalciuric hypercalcemia (FHH)

    PTHrP Solid tumors malignant: lung, head/neck, esophagus, prostate, breast, lymphoma Solid tumors benign: uterine myoma, pheochromocytoma Leukemia or multiple myeloma

    1,25 vitamin D Lymphoma Granulomatous disease: sarcoid, granulomatous myositis, histiocyte disordres

    (Langerhans) Inflammatory Crohns, Wegeners, SLE, foreign bodies, beryliosis Infections TB, fungal disease CYP24A1 mutations

    Excessive bone resorption: immobilization, hyperthyroidism Excessive calcium intake milk alkalai syndrome Vitamin D intoxication: D2, D3, analogs Drugs: HCTZ, lithium, high dose vitamin A Adrenal insufficiency

  • Bilezikian JP et al JCEM 2014;99:3561

    Calcium 1 mg/dl above upper limit of normal

    at lumbar spine, total hip, femoral neck or

    Vertebral fracture by VFA, radiograph, CT, or MRI

    Creatinine clearance 400 mg/day

    Nephrolithiasis or nephrocalcinosis by radiograph, CT or ultrasound

    Bilezikian JP et al JCEM 2014;99:3561

  • Measure PTH

    Suppressed

    Measure 1,25 OH Vit D, PTHrP, SPEP,

    UPEP

    Normal or high 1,25 vitamin OH D

    Evaluate for 1,25 OH mediated causes

    Elevated PTHrP

    Evaluate for malignancy, myeloma

    Elevated SPEP/UPEP

    Myeloma

    Normal or Elevated

    24 hr urine Ca, Na, Cr, calcium clearance

    Clearance 0.01

    Primary Hyperparathyroidism

  • Measure PTH

    Suppressed

    Measure 1,25 OH Vit D, PTHrP, SPEP,

    UPEP

    Normal or high 1,25 vitamin OH D

    Evaluate for 1,25 OH mediated causes

    Elevated PTHrP

    Evaluate for malignancy, myeloma

    Elevated SPEP/UPEP

    Myeloma

    Normal or Elevated

    24 hr urine Ca, Na, Cr, calcium clearance

    Clearance 0.01

    Primary Hyperparathyroidism

  • Measure PTH

    Suppressed

    Measure 1,25 OH Vit D, PTHrP, SPEP,

    UPEP

    Normal or high 1,25 vitamin OH D

    Evaluate for 1,25 OH mediated causes

    Elevated PTHrP

    Evaluate for malignancy, myeloma

    Elevated SPEP/UPEP

    Myeloma

    Normal or Elevated

    24 hr urine Ca, Na, Cr, calcium clearance

    Clearance 0.01

    Primary Hyperparathyroidism

  • Jacobs, TP et al JCEM 2014;99:708-712

  • Brandi ML et al. J Clin Endocrinol Metab. 2016;doi: 10.1210/jc.2015-3907

  • Bilezikian JP et al. J Clin Endocrinol Metab. 2016;doi: 10.1210/jc.2015-3910

  • Bilezikian JP et al. J Clin Endocrinol Metab. 2016;doi: 10.1210/jc.2015-3910

    Bilezikian JP et al. J Clin Endocrinol Metab. 2016;doi: 10.1210/jc.2015-3910

  • Bilezikian JP et al. J Clin Endocrinol Metab. 2016;doi: 10.1210/jc.2015-3910

    Enhances calcium absorption, stimulates bone remodeling

    Overdosing detected early by urine calcium elevations

    Active metabolites

    Calcitriol (1,25 vitamin D3) half life 4-6 hours, peak levels 3-6 hours

    0.25-0.5 mcg twice daily typically up to total of 2 mcg daily

    Increases calcium levels within 1-3 days

    Alfacalcidol (1-hydroxyvitamin D3) (not in USA)

    About 2 mcg/day

    Onset 1-3 days

    Offset 5-7 days (longer half life than calcitriol)

    Bilezikian JP et al. J Clin Endocrinol Metab. 2016;doi: 10.1210/jc.2015-3910

  • Vitamin D3 (or D2) in addition to active metabolites

    Longer half-life 2-3 weeks (recovery from overdose can take weeks)

    Especially useful if some parathyroid function (25 to 1,25 conver

    Bilezikian JP et al. J Clin Endocrinol Metab. 2016;doi: 10.1210/jc.2015-3910

    Bilezikian JP et al. J Clin Endocrinol Metab. 2016;doi: 10.1210/jc.2015-3910

  • How often do you see a patient with a previous DXA report interpretation that is incorrect?

    Lewiecki, EM, et al. J Clin Densitom, 9:388-392, 2006

    30

    25

    20

    15

    10

    5

    0

    Perc

    en

    tage

    of

    Re

    sp

    on

    ders

    > 1/day > 1/week 1/week 1/month 50)

    Lumbar spine, total hip, femoral neck and one-third radius

    World Health Organization. Technical Report Series 843; WHO, Geneva.1994.

    Kanis JA et al. J Bone Miner Res. 1994;9:1137.

    T-score (SD)

    Normal Equal to -1.0 or higher

    Low Bone Mass (Osteopenia) Between -1.0 and -2.5

    Osteoporosis Equal to -2.5 or lower

    Severe Osteoporosis Equal to -2.5 or lower with fracture