Home' Australian Pharmacist : Australian Pharmacist Nov 2013 Contents 42 Australian Pharmacist November 2013 I ©Pharmaceutical Society of Australia Ltd.
vitamin D.23 Furthermore, increasing
serum PTH levels were associated with
the dosage of frusemide.
In addition, hypercalcaemia and
hyperparathyroidism have been
described as under-recognised potential
complications of lithium therapy, which
may occur more frequently in older
patients.24--27 It has been suggested
that psychiatrists should be vigilant in
screening for hyperparathyroidism in
their older patients receiving lithium,
both prior to starting treatment and at
least annually thereafter.24
Correction of vitamin D deficiency and
appropriately managing renal disease are
the key strategies to prevent secondary
hyperparathyroidism. Mild vitamin D
deficiency (serum 25-hydroxyvitamin
D levels in the range 25-50 nmol/L or
10-20 ng/mL) leads to increased PTH
secretion and high bone turnover.28
The serum 25-hydroxyvitamin D threshold
value to avoid adverse health events is
around 75 nmol/L (30 ng/mL).29 According
to Therapeutic Guidelines, the serum
25-hydroxyvitamin D concentration
(the best indicator of vitamin D status)
should be maintained at 75 nmol/L (30
ng/mL) or more as part of the prevention
and treatment of osteoporosis in older
people.30 Vitamin D supplementation,
in the form of cholecalciferol 25 to 50
micrograms (1000 to 2000 international
units) daily, is indicated in proven
vitamin D deficiency, in institutionalised
or housebound people, and in women
who are veiled for cultural reasons.30
People who are vitamin D-deficient
require higher doses: cholecalciferol
75 to 125 micrograms (3000 to
5000 international units) daily is
required for at least 6-12 weeks to treat
moderate-to-severe deficiency; this will
usually return serum 25-hydroxyvitamin
D threshold levels to the normal range
and allow ongoing treatment with a lower
dose (e.g. 1000 international units daily).2
Figure 2. Association of ageing with secondary hyperparathyroidism
1. Fraser WD. Hyperparathyroidism. Lancet. 2009;374(9684):145-58.
2. Lips P. Vitamin D deficiency and secondary hyperparathyroidism
in the elderly: consequences for bone loss and fractures and
therapeutic implications. Endocr Rev. 2001;22(4):477-501.
3. Jamal SA, Miller PD. Secondary and tertiary hyperparathyroidism.
Journal of clinical densitometry: the official journal of the
International Society for Clinical Densitometry. 2013;16(1):64-8.
4. Cozzolino M, Pasho S, Fallabrino G, Olivi L, Gallieni M, Brancaccio
D. Pathogenesis of secondary hyperparathyroidism. The
International journal of artificial organs 2009;32(2):75-80.
5. Taniegra ED. Hyperparathyroidism. American family physician.
6. Mosekilde L. Vitamin D and the elderly. Clin Endocrinol (Oxf ).
7. Malik R. Vitamin D and secondary hyperparathyroidism in
the institutionalized elderly: a literature review. J Nutr Elder.
8. Premaor MO, Furlanetto TW. Vitamin D deficiency in adults: to
better understand a new presentation of an old disease. Arq Bras
Endocrinol Metabol. 2006;50(1):25-37.
9. Terauchi M. Bone and calcium metabolism in menopause
transition. Clin Calcium 2011;21(9):1353-9.
10. Christakos S, Dhawan P, Porta A, Mady LJ, Seth T. Vitamin
D and intestinal calcium absorption. Mol Cell Endocrinol
11. Youssef DA, El Abbassi AM, Cutchins DC, Chhabra S, Peiris
AN. Vitamin D deficiency: implications for acute care in the
elderly and in patients with chronic illness. Geriatr Gerontol Int.
12. de Francisco AL. Secondary hyperparathyroidism: review
of the disease and its treatment. Clinical therapeutics.
13. Peiris AN, Youssef D, Grant WB. Secondary hyperparathyroidism:
benign bystander or culpable contributor to adverse health
outcomes? South Med J. 2012;105(1):36-42.
14. Horl WH. The clinical consequences of secondary
hyperparathyroidism: focus on clinical outcomes. Nephrol Dial
Transplant. 2004;19 Suppl 5:V2-8.
15. Kritchevsky SB, Tooze JA, Neiberg RH, Schwartz GG, Hausman DB,
Johnson MA, et al. 25-Hydroxyvitamin D, parathyroid hormone,
and mortality in black and white older adults: the health ABC
study. J Clin Endocrinol Metab. 2012;97(11):4156-65.
16. Sambrook PN, Chen JS, March LM, Cameron ID, Cumming RG,
Lord SR, et al. Serum parathyroid hormone is associated with
increased mortality independent of 25-hydroxy vitamin d status,
bone mass, and renal function in the frail and very old: a cohort
study. J Clin Endocrinol Metab. 2004;89(11):5477-81.
17. Premaor MO, Scalco R, da Silva MJ, Furlanetto TW. Secondary
hyperparathyroidism is associated with increased risk of
hospitalization or death in elderly adults living in a geriatric
institution. Gerontology 2009;55(4):405-10.
18. Cawthon PM, Parimi N, Barrett-Connor E, Laughlin GA, Ensrud
KE, Hoffman AR, et al. Serum 25-hydroxyvitamin D, parathyroid
hormone, and mortality in older men. J Clin Endocrinol Metab.
19. Curtis JR, Ewing SK, Bauer DC, Cauley JA, Cawthon PM, Barrett-
Connor E, et al. Association of intact parathyroid hormone levels
with subsequent hip BMD loss: the Osteoporotic Fractures in
Men (MrOS) Study. J Clin Endocrinol Metab. 2012;97(6):1937-44.
20. Fisher A, Goh S, Srikusalanukul W, Davis M. Elevated serum PTH is
independently associated with poor outcomes in older patients
with hip fracture and vitamin D inadequacy. Calcif Tissue Int.
21. Venkataraman PS, Han BK, Tsang RC, Daugherty CC. Secondary
hyperparathyroidism and bone disease in infants receiving long-
term furosemide therapy. Am J Dis Child. 1983;137(12):1157-61.
22. Coe FL, Canterbury JM, Firpo JJ, Reiss E. Evidence for secondary
hyperparathyroidism in idiopathic hypercalciuria. J Clin Invest.
23. Stein MS, Scherer SC, Walton SL, Gilbert RE, Ebeling PR, Flicker L,
et al. Risk factors for secondary hyperparathyroidism in a nursing
home population. Clinical endocrinology 1996;44(4):375-83.
24. Lehmann SW, Lee J. Lithium-associated hypercalcemia and
hyperparathyroidism in the elderly: what do we know? J Affect
25. Albert U, De Cori D, Aguglia A, Barbaro F, Lanfranco F,
Bogetto F, et al. Lithium-associated hyperparathyroidism and
hypercalcaemia: A case-control cross-sectional study. J Affect
Disord 2013 (in press). DOI: 10.1016/j.jad.2013.06.046
26. Saunders BD, Saunders EF, Gauger PG. Lithium therapy and
hyperparathyroidism: an evidence-based assessment. World J
27. Broome JT, Solorzano CC. Lithium use and primary
hyperparathyroidism. Endocr Pract 2011;17 Suppl 1:31-5.
28. Osteoporosis. Australian Medicines Handbook, Aged Care
Companion Online: Australian Medicines Handbook Pty Ltd,
29. Annweiler C, Souberbielle JC, Schott AM, de Decker L, Berrut
G, Beauchet O. Vitamin D in the elderly: 5 points to remember.
Geriatr Psychol Neuropsychiatr Vieil. 2011;9(3):259-67.
30. Prevention of osteoporosis [revised June 2009, amended
February 2011]. In: eTG complete [CD-ROM]. Melbourne:
Therapeutic Guidelines Limited; 2013 July, etg40.
excretion and can
lower serum calcium,
thereby increasing the
release of PTH.'
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