UK national chronic hypoparathyroidism audit

Abstract

Objectives: Individuals with chronic hypoparathyroidism may experience suboptimal medical care with high frequency of unplanned hospitalisation and iatrogenic harm. In 2015 the European Society for Endocrinology published consensus guidelines on the management of chronic hypoparathyroidism. We set out to audit compliance with these guidelines.

Methods: Using these recommendations as audit standards we worked with the Society for Endocrinology and Parathyroid UK to conduct a national audit of management of chronic hypoparathyroidism in the United Kingdom. Endocrine leads in 117 endocrine departments were invited to participate in the survey by completing a data collection tool on up to 5 sequential cases of chronic hypoparathyroidism seen in their outpatient clinics in the preceding 12 months. Data were collected on 4 treatment standards and 9 monitoring standards. Data on hospitalisations and Quality of Life monitoring were also collected.

Results: Responses were received from 22 departments giving a response rate of 19%, concerning 80 individual cases. The mean age of subjects was 48.4 years. The main findings were that the commonest cause of hypoparathyroidism was post surgical (66.3%). Treatments taken by the group included activated vitamin D analogues (96.3%), oral calcium salts (66.3%), vitamin D supplements (17.5%), thiazide diuretics (5%) and rhPTH_1-34 (1.3%). Compliance with the audit standards varied between 98.8% and 60% for the treatment standards and between 91.3% and 20% for the monitoring standards. Some of the areas of weakness revealed include low rates of 24 h urinary calcium excretion monitoring, serum magnesium monitoring and low rates of renal imaging where indicated. In addition and importantly, 16.3% of subjects had experienced at least one hospital admission in the preceding 12 months.

Conclusion: We conclude that further improvements in the UK national standard of management of chronic hypoparathyroidism should be made and that this will benefit both quality of life, morbidity and potentially mortality in this group of patients.

Keywords: calcium; conditions; hypocalcemia; hypoparathyroidism; parathyroid.

Figure 1

Audit data organised by audit standard. (A) Treatment standards. (1) Recommend treatment of all patients with chronic Hypoparathyroidism with an albumin adjusted serum calcium level <2.0 mmol/L. (2) Recommend the use of activated vitamin D analogues plus calcium supplements in divided doses as the primary therapy. (3) Recommend against the routine use of replacement therapy with PTH or PTH analogues. (4) Recommend vitamin D supplementations in a daily dose of 400–800 IU to patients treated with activated vitamin D analogues. (B) Monitoring standards. (5) Recommend routine biochemical monitoring of adjusted calcium (e.g., every 3–6 months). (6) Recommend routine biochemical monitoring of phosphate (e.g., every 3–6 months). (7) Recommend routine biochemical monitoring of magnesium (e.g., every 3–6 months). (8) Recommend routine biochemical monitoring of creatinine (e.g., every 3–6 months). (9) Recommend routine biochemical monitoring eGFR (e.g., every 3–6 months). (10) Recommend routine assessment of symptoms of hypocalcaemia and hypercalcaemia at regular time intervals (e.g., every 3–6 months). (11) Suggest considering monitoring of 24‐h urinary calcium excretion at regular intervals (1–2 yearly). (12) Recommend renal imaging if a patient has symptoms of renal stone disease or if serum creatinine levels start to rise. (13) Advise against routine monitoring of bone mineral density (BMD) by dual energy X‐ray absorptiometry (DXA) scans. (C) Additional standards. (14) Percentage of patients who had required inpatient care in the preceding 12 months, (15) Percentage of patients who had undertaken a QoL questionnaire