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Osteoporosis, Fatigue, and Kidney Stones: What is My Parathyroid Doing?

Online Health Chat with Dr. Krupa Doshi

July 14, 2011


Introduction

The parathyroid glands regulate calcium levels in the body. Parathyroid disorders may cause a loss of energy, osteoporosis, kidney stones, depression, and many other symptoms. Diagnosis and treatment are key to managing a parathyroid problem and will help to control the related symptoms. Join endocrinologist Dr. Krupa Doshi for answers to your questions concerning the entire spectrum of parathyroid disease and its treatment options.

Krupa Doshi, MD, is an endocrinologist in Cleveland Clinic’s Endocrinology & Metabolism Institute. She is board certified in endocrinology and internal medicine, and her specialty interests include general endocrinology, parathyroid and calcium disorders, osteoporosis, diabetes, hirsutism, thyroid disorders, and adrenal disorders.

A graduate of the University of Bombay, Seth G.S. Medical College, Dr. Doshi completed her residency in internal medicine at Saint Luke’s Roosevelt Hospital Center in New York. She completed her endocrinology fellowship at Cleveland Clinic.

To make an appointment with Krupa Doshi, MD, or any of the specialists in the Endocrinology & Metabolism Institute at Cleveland Clinic, please call 216.444.6568 or call toll-free at 800.223.2273, ext. 46568. You can also visit us online at www.clevelandclinic.org/endocrinology.

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Krupa Doshi. We are thrilled to have her here today for this chat. Let’s begin with some of your questions.


Parathyroid Basics

cradle2:What does the parathyroid do?

Dr__Krupa_Doshi: The parathyroid gland produces the parathyroid hormone that maintains calcium and phosphorus balance in the body.

believe_it: What is PTH?

Dr__Krupa_Doshi: PTH stands for parathyroid hormone.

to_be_or_not: What are the risks of parathyroid disease?

Dr__Krupa_Doshi: Often, people develop parathyroid disease from a benign tumor, or from one or more glandular enlargements. Sometimes, the disease runs in families and can occur with some other endocrine gland overactivity. Many times, it can occur without any reason.

Parathyroid problems commonly occur from long-standing kidney disease.


Symptoms and Treatment

clay_ton: What symptoms would indicate a parathyroid problem?

Dr__Krupa_Doshi: Most patients with a parathyroid problem have no symptoms, and a routine blood test tells the physician that there may be an issue. Some patients may have subtle and non-specific symptoms, such as muscle and joint aches and pains, increased urination, and an inability to think clearly (foggy memory). More clear-cut signs and symptoms are bone loss (may show up on bone density test) and kidney stones.

finite: How is parathyroid disease treated?

Dr__Krupa_Doshi: The BEST treatment for primary parathyroid disease (that could occur from a benign parathyroid adenoma or enlargement of multiple parathyroid glands) is surgery. This can be curative.

For parathyroid disease that is from long-standing kidney disease, and which is not responsive to medical treatment, surgery is the best option as well.

Occasionally, when patients are not good candidates for surgery, bisphosphonates and some other medications may be used to prevent bone loss.


Medications

Lstrand: I will start using the synthetic parathyroid hormone Forteo® in the near future to build bone density. Is there a recommendation as to how long someone should wait to start using Forteo® after having been on Fosamax®? When using Forteo®, are there special considerations regarding calcium intake?

Dr__Krupa_Doshi: It is best to start Forteo® (teriparatide) right after discontinuing Fosamax® (alendronate). Forteo® can increase blood and urine calcium levels transiently. So my recommendation would be: if you are getting enough calcium in your diet (via dairy and other calcium-rich food), it is best to avoid supplements.

Tumbleweed: I take Boniva® and Synthroid. Would it be better to take Forteo®? I did have high blood pressure, but no longer do since I have been exercising regularly and drinking more water.

Dr__Krupa_Doshi: If Boniva® (ibandronate) is working for you, there is no need to switch to Forteo®. Blood work and bone density scans can point you (and your physician) in the right direction. Having an underactive thyroid and taking Synthroid (levothyroxine) will not affect your bone health unless you are taking too much (since too much Synthroid can contribute to bone loss). I am glad to hear that your BP is normal!


Vitamin D

sylviaj: When someone has vitamin D deficiency (16) and low calcium, can that cause stone formation? Someone told me that calcium can be leached from bones (unregulated) during vitamin D deficiency and that can lead to secondary hyper or hypo parathyroidism. If someone has thyroid symptoms but the PTH test is normal, then what is going on? Thank you!

Dr__Krupa_Doshi: Let me say that most patients with vitamin D deficiency and low calcium do not have stones. However, low calcium levels (from lack of calcium in the diet and/or supplements) can cause recurrent stones in a person who is predisposed to stone formation. Kidney stones can occur from a variety of causes.

To answer your second question, thyroid and parathyroid glands do completely different things. So if someone has thyroid symptoms, they should have a thyroid panel run.

jasajass: How much vitamin D do you recommend for good bone health, and can it reverse osteoporosis?

Dr__Krupa_Doshi: Most adult patients, in my experience, seem to need somewhere between 1000 to 3000 IU of vitamin D daily. BUT, there is a WIDE variation in the amounts, and the best way to determine the best dose for you is to have your levels tested.

Loss of bone density can occur with really low vitamin D levels, and I have seen bone density significantly improve when these patients' vitamin D stores are replenished.

jasajass: My blood level of vitamin D has not been tested, but if it should test extremely low, how much vitamin D supplementation would you recommend? Are there any upper limits above which it would be toxic?

Dr__Krupa_Doshi: I usually start with 50,000 IU once or twice a week depending on how low the levels are and after making sure the calcium level is not high. Blood tests should be done two to three months later, and the dose can be adjusted based on the results. Levels above 80 to 100 (I am not sure of the units here) are considered to be in the toxic range.


Testing

Katelynn: Will thyroid tests also detect problems in the parathyroid glands?

Dr__Krupa_Doshi: No. The thyroid and parathyroid glands do completely different things. They have similar sounding names, since they are in the same area of the body (front of the neck). A thyroid panel (TSH and free T4) will give a good idea of a thyroid problem. Most parathyroid gland problems (the most common being an overactive gland) are detected on a calcium lab test.

MARTINL86: What types of tests are used to determine thyroid or parathyroid problem in a patient? I have been on Fosamax® for nearly a year and calcium supplements for over a year. I have occasional severe fatigue symptoms and depression.

Dr__Krupa_Doshi: The best screening thyroid tests are TSH and free T4. The best tests for a parathyroid problem are serum calcium, PTH, and 25 hydroxy vitamin D.

There are many causes of severe fatigue and depression, and I think it may be best to see a physician for a complete work-up.


Osteoporosis, Kidney Stones, and other Disorders

gabbyme3: I have osteoporosis and a history of kidney stones since my teenage years. If I take calcium for the osteoporosis, I get a lot of kidney stones. So what can I take or do to stop bone loss and not have a bunch of kidney stones to deal with? I am 75 years old. And thank you for your feedback.

Dr__Krupa_Doshi: Kidney stones actually recur more from LOW calcium. In your case, it may be much better to get all of your calcium needs met from DIET rather than supplements. Calcium from diet is much less likely to cause problems with stone recurrence. A bisphosphonate and adequate vitamin D is also advisable for osteoporosis, along with calcium.

You may want to work with an endocrinologist to make sure you are getting the current amount of dietary calcium, and he or she may also recommend a 'kidney stone' diet.

gabbyme3: I also was taking Actonel® 35mg once a week for 10+ years, but stopped taking it this past year because my last DXA scan showed I lost bone density (T-score: L/S spine: -2.9 and hip: -2.3). Do I need to take a drug holiday from the Actonel®?

Dr__Krupa_Doshi: Bone loss after taking Actonel® (risedronate) for 10+ years means (1) your body may not have absorbed it at all or (2) it did not work for you.

Since you have osteoporosis based on your bone density results, you should be on another agent, such as a more potent bisphosphonate or a bone-forming agent such as teriparatide. I would recommend you see a bone specialist to discuss the pros and cons, and see what's best for you!

Katelynn: Is there a relationship between hyperparathyroidism and breast cancer?

Dr__Krupa_Doshi: Yes. There has been some implication between hyperparathyroidism and breast cancer in some studies.

vion38: If a person is experiencing fatigue, what should be looked at, especially with the parathyroid?

Dr__Krupa_Doshi: There are many causes of fatigue. To rule out a parathyroid problem, it may be worth checking a calcium PTH and a vitamin D level. Vitamin D deficiency often causes fatigue.

MARTINL86: In addition to the fatigue and depression, I also have had many bouts with gastrointestinal discomfort. Could this be related in any way with the thyroid, parathyroid, Fosamax®, and calcium supplements?

Dr__Krupa_Doshi: This is a very general question, and it is hard for me to give a more definite answer. An overactive parathyroid gland can cause abdominal pain. Fosamax® can also cause some stomach discomfort. Calcium supplements usually don't cause stomach discomfort. Thyroid problems uncommonly present with gastrointestinal discomfort, but can easily be picked up by a simple blood test.

dixzeland: Is it common for a patient with hyperparathyroid disease to be diagnosed with POTS? I know there are many symptoms related to hyperparathyroidism. How common is it to have high blood pressure with tachycardia?

Dr__Krupa_Doshi: I am not aware of an association between hyperparathyroidism and POTS (postural orthostatic tachycardia syndrome).

To answer your second question, most (80 percent or more) patients with hyperparathyroidism have no symptoms. However, high blood pressure has been associated with hyperparathyroidism and could be one of the many symptoms that may arise with the disease.


General Questions

Tumbleweed: If your therapeutic range for thyroid is at 1/4 range, and you are still sleeping 9 to 9½ hours a day, should your medication be changed?

Dr__Krupa_Doshi: I am sorry. I don't understand your question about the range being at 1/4 range.

clara: I was on Fosamax® for 13 years and went off of it two years ago. I just had a bone scan and the reading is about the same. My hip is -2.7 and the spine is -2.2. I asked the doctor about Forteo®, but he said I need to have a break before getting it. I did break ribs about 10 years ago. I am not sure what he is telling me. I am somewhat concerned with the hip. He did give me Evista® (raloxifene), but I am not sure how much good it will do. Can you advise me? Is there a way I can send records to Cleveland Clinic to get advice? I know they do this for the heart.

Dr__Krupa_Doshi: Cleveland Clinic has a second opinion service for all of our specialties. The website is www.eclevelandclinic.org/ for additional information. You will need to copy and paste this into the address bar.

desmond: My cousin found out she had a parathyroid problem because of something that was happening to her fingernails. What is this and how would this be an indicator?

Dr__Krupa_Doshi: I am not aware of any relationship between a parathyroid problem and fingernails.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Krupa Doshi is now over. Thank you again Dr. Doshi for taking the time to answer our questions today about Osteoporosis, Fatigue, and Kidney Stones: What is My Parathyroid Doing?

Dr__Krupa_Doshi: This has been a fantastic opportunity for me! Thank you for all the great questions. If any of you would like a consultation, we now offer a 'Calcium Clinic' at the Endocrinology & Metabolism Institute at Cleveland Clinic Main Campus.


More Information

To make an appointment with Krupa Doshi, MD, or any of the specialists in the Endocrinology & Metabolism Institute at Cleveland Clinic, please call 216.444.6568 or call toll-free at 800.223.2273, ext. 46568. You can also visit us online at www.clevelandclinic.org/endocrinology.

A remote second opinion may also be requested from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, visit www.eclevelandclinic.org/myConsult.

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This chat occurred on July 14, 2011

This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. ©Copyright 1995-2011 The Cleveland Clinic Foundation. All rights reserved.


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