Dear Mohammad
Based on getting asked about several of these
patients each year (albeit not usually as severe)
rather than any detailed clever pathophysiological
calculations. Patients who develop severe
hypocalcaemia on bisphosphonates (Zolendronate a
common recent culprit) are most often elderly,
often with prostate cancer, extensive disease and
underlying vitamin D deficiency or even
osteomalacia. Even with Vitamin D insufficiency
(eg 25(OH)D less than 30nmol/L) I would certainly
recommend adequate Vitamin D supplementation.
Rarely, patient are unable to mount an adequate
parathyroid response. This can be due to
previously undiagnosed hypoparathyroidism or
coexistent hypomagnesaemia. I would certainly
measure PTH and magnesium.
A few formal case reports of this problem (eg
Fraser in BMJ and others).
Aubrey
MAJ> Aubery,
MAJ> I couldn't understand how you made a decisive
MAJ> diagnosis of vitamin D deficiency in this patient?
MAJ> My simple explanation is bisphosphonate induced
MAJ> hypomagnesaemia leading to hypocalcaemia and
MAJ> hypokalaemia. I must be missing some obvious
MAJ> pathophysiology and would therefore be grateful for
MAJ> further explanation.
MAJ> Best wishes
MAJ> Mohammad
MAJ> --- [log in to unmask] wrote:
>> Not uncommon. He will have Vitamin D deficiency.
>> Ca Prostate is also a common scenario where this
>> happens more commonly (osteoblastic mets). Suggest
>> they give him a decent amount of Vitamin D (usual
>> oral supplements are homeopathic) such as imi
>> calciferol 300,000 Units IMI, as well as oral
>> supplements (high dose oral D if locally
>> obtainable). Check his plasma 25(OH)D before
>> administering for the record.
>>
>> Sounds as if he should be in hospital for some iv
>> magnesium/Ca/K until he gets over his immediate
>> problems.
>>
>> Aubrey
>>
>> --
>> /\=========================================
>> || Dr Aubrey Blumsohn
>> || Senior Lecturer in Metabolic Bone Disease
>> || Bone Metabolism Laboratory
>> || Human Nutrition Unit
>> || Division of Clinical Sciences (NGHT)
>> || Clinical Sciences Centre
>> || Northern General Hospital, Herries Road
>> || Sheffield S5 7AU, England
>> || Email: [log in to unmask]
>> || Tel: 114-2715963(office)
>> || Fax: 0114 261 8775 (fax)
>> \/=========================================
>>
>> GM> A patient with Ca Prostate was given
>> GM> monthly infusions of Bisphosphonates
>> GM> not for Hypercalcaemia, but to reduce his bone
>> pain.
>> GM> On commencing his Calcium was 2.36, Alk.
>> GM> Phos 133, Potassium 3.4 and
>> GM> Creatinine 146.
>> GM> He went for 5 months without further
>> GM> calcium measurements, but when they
>> GM> were done his Calcium was 1.65, Alk. Phos
>> GM> 267, Potassium 2.9 and Creatinine
>> GM> 211.
>> GM> GP was going to discuss with oncologist
>> GM> and put patient on oral Calcium,
>> GM> Magnesium and Vitamin D following the
>> GM> following set of results, Calcium
>> GM> 1.49, Alk. Phos 304, Potassium 3.1,
>> GM> Creatinine 201, Magnesium 0.45. Patient
>> GM> now complaining of cramps and muscle
>> GM> weakness, and can't walk down the
>> GM> corridor to GP's consulting room.
>> GM> Most recent results similar, Calcium
>> GM> 1.67, Alk. Phos 294, Potassium 3.3,
>> GM> Creatinine 132, Magnesium 0.46.
>> GM> BNF suggests check for hypocalcaemia
>> GM> before start treatment, but can't find
>> GM> anything about how long it will take to
>> GM> rectify this medically induced set
>> GM> of abnormal Biochemistry results. I don't
>> GM> think it will be a quick fix
>> GM> cure, especially if they continue with
>> GM> the monthly infusions.
>> GM> Has anyone else seen this before, if so
>> GM> any advice on timescales would be
>> GM> welcome.
>>
>> GM> Regards,
>> GM> Gary
>>
>> GM> G.C. Mascall
>> GM> Clinical Biochemistry Department
>> GM> Kidderminster & Redditch
>> GM> Worcestershire
>>
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>>
>> Regards
>>
>> Aubrey Blumsohn
>>
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MAJ> Dr. M A Al-Jubouri
MAJ> Consultant Chemical Pathologist
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Regards
Aubrey Blumsohn
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