Online Health Chat with Susan Williams, MD, and Leila Khan, MD

July 14, 2016

Description

Abnormal calcium-related disorders such as kidney stones, hypocalcemia, vitamin D deficiency, hyperparathyroidism and osteoporosis can have devastating effects on your health and well-being. Diagnosis and treatment are keys to managing these conditions, and will help to control symptoms and decrease the risk of other related, complex problems. Join endocrinologist Dr. Leila Khan and internist Dr. Susan Williams online for answers to your questions concerning calcium metabolism disorders, symptoms to watch out for and the latest treatment options available.


About the Speakers

Leila Khan, MD, is a specialist in the Endocrine Calcium Clinic and a staff physician in the Endocrinology & Metabolism Institute. She is board certified in internal medicine and endocrinology, diabetes and metabolism. She graduated medical school from the University of Maryland, completed an internal medicine residency and chief residency at Hershey Medical Center and went on to complete her fellowship in endocrinology at the University of Pittsburgh. Dr. Khan’s specialty interests include diabetes, hypercalcemia, osteopenia, parathyroid and calcium disorders, and vitamin D deficiency.

Susan Williams, MD, is a specialist in the Endocrine Calcium Clinic and a staff physician in the Endocrinology & Metabolism Institute. She earned her undergraduate degree from Kansas State University, a Master's degree in nutrition from the University of Rhode Island, and served as an officer, nutrition professional and reservist in the U.S. Air Force. She completed medical school at Wright State, a residency at Kettering Medical Center and a fellowship in clinical nutrition and metabolism at Cleveland Clinic. Dr. Williams is board-certified in nutrition, obesity medicine, internal medicine and densitometry, and is a diplomate of the American Board of Obesity Medicine and the American Board of Physician Nutrition Specialists. Dr. William’s specialty interests include: bone and mineral metabolism, metabolic bone disease, malabsorption and malnutrition in adults, medical bariatrics, clinical nutrition, human nutrition, and mentoring and teaching.


Let’s Chat About Calcium Disorders

Tests and Measurements

Leahh: What are the acceptable ranges of blood calcium for people over the age of 50?

Susan_Williams,_MD: A normal level of calcium in the blood will vary somewhat because every lab is a bit different; but in general, the acceptable range is between 8.6 and 10.6 mg/dL. If you have questions about your calcium level, be sure to review the results with your physician so that he or she can interpret it for you in the context of your health.

smartini: Is there a blood test that can give you an indication of whether or not Fosamax is working after you've been on it for about six months?

Leila_Khan,_MD: Bone markers can be helpful in determining whether the bone agents are working well, since they are typically low when medication is being absorbed. Bone markers prior to and after treatment can be a nice indication that the medication is working well.

Leahh: I am a dietitian and have been diagnosed with primary hyperparathyroidism at calcium levels that fluctuate between 10.1 and 10.9, PTH in the eighteens. I am learning of contradictory approaches regarding surgery. I am familiar with the official guidelines and criteria that indicate surgery but am also concerned about quality of life if choosing the path of "wait and see." Should the focus be on level of calcium or on how long levels have been elevated?

Susan_Williams,_MD: Great question! From just the information you have shared, it sounds like very mild hyperparathyroidism and in that case, surgery is often not recommended. The guidelines that we use include kidney function, history of kidney stones and history of fractures, among other things. The length of time that your calcium has been elevated and the degree of elevation are considerations. However, that is just one of many things we and our endocrine surgery colleagues look at when contemplating surgery. I would also like to recommend scheduling an appointment with one of us so that we can discuss the specifics of your situation and help in the decision-making process.


Lifestyle Links

Dina2345: I read somewhere that taking calcium (plus D) tablets with “too much caffeine” negates the effects of the calcium. What do they mean by “too much caffeine”?
Does this mean NOT to take calcium tablets (plus D) with coffee?

Susan_Williams,_MD: This is a great question! Any beverages, foods or supplements that contain caffeine or other stimulants such as the caffeine in coffee and pop, tannins in tea, green tea extract or even cocoa can cause a loss of calcium through the urine, known as calciuria. How much is too much caffeine? The current recommendation is to limit oneself to no more than two small cups of caffeinated beverages daily.


Stone Sufferers

chatter23: I had a large kidney stone and found out I have severe hyperoxaluria. I am female and I had been taking 2000 IU vitamin D a day and no calcium. I didn't have a lot of calcium in my urine. I follow a vegetarian, low-dairy diet. Now I am to take calcium with food to bind to oxalates. How likely is it that vitamin D contributed to my stone, and do I need to be careful with D now?

Leila_Khan,_MD: Great question. Your kidney stones, since they are oxalate based and not calcium based, are probably unrelated to vitamin D intake. In short, you do not need to worry about vitamin D intake and should aim for a level in the normal range of 30 to 50 ng/dL.

gabbyme3: I have a history of kidney stones, all calcium related, so in my earlier years I ate and drank no calcium products, and that led to thin bones (osteoporosis) and poor teeth. My family doctor put me on Actonel for about ten years, and all that did was build up a deposit of calcium on my heart valves (aorta valve), leaving me with a heart murmur. Please, what would you do it you had a calcium disorder? Thank You, doctor, for your input today.

Leila_Khan,_MD: Thank you for your question. There are several treatments for kidney stones. However, it is not the usual standard of care to be put on a low calcium diet. Your diet should be low in salt and high in water, but calcium-rich foods are good for you even with this history. Regarding the treatment of stones, you should see an endocrinologist to run labs and ensure that there is no condition called hyperparathyroidism (which can cause stones). There can also be medications given to prevent additional stones. Regarding the treatment of osteoporosis, you should certainly see an endocrinologist since we have a variety of treatments for this, and the bone loss you have may even be secondary to the underlying cause of the kidney stones. Good luck.


Mixed Maladies

Pehartman: I am a 55-year-old male who has the following calcium-related medical issues: osteoporosis (taking Forteo injections and vitamin D supplements) and kidney stones (taking hydrochlorothiazide and potassium citrate plus low sodium diet, litho link testing). I have been tested for parathyroid problems (negative), and an MRI of my pituitary showed possible microadenoma, which has not increased in size. I have also had many blood tests. I have normal blood levels of calcium and vitamin D. I exercise regularly, lift weights three time a week and do yoga. Can you suggest any other possible treatments or approaches to managing my disorder?

Susan_Williams,_MD: Thank you for your question. You have very important and complex questions that deserve answers. Please consider scheduling an appointment with one of us in our Endocrine Calcium Clinic. We would be glad to discuss the specifics of your bone and calcium-related health issues.

mariearc2015: I have mitral annular calcification and calcified atherosclerotic plaque on my thoracic aorta. Could this be caused by the calcium in my diet? Should I watch my calcium intake? If not dietary calcium, what is the cause of calcification on our arteries?

Susan_Williams,_MD: Calcification of arteries and heart valves is due to cardiovascular disease and is not due to calcium intake except in VERY rare circumstances. The National Osteoporosis Foundation recommends getting adequate calcium from your diet first and taking calcium supplements only if your diet falls short. Aim for about 1000 mg of calcium TOTAL, remembering that an 8 oz. glass of milk or a cup of yogurt will provide about 300 mg of calcium.

Marigold: I have idiopathic hypercalciuria and take Indapamide for it. Without it my urine calcium loss is around 650. With Indapamide, it's around 300. I've been taking this for five years. My serum calcium is always normal. I was diagnosed with osteoporosis at age 50 and became postmenopausal at 52; I am now 60. I continue to suffer bone loss, mainly in my spine. I get adequate calcium from my diet because I learned supplements give me kidney stones. I have to be careful with vitamin D supplements because my d,125 goes too high. I know vitamin D is important for my bones, but if my level is under 30, does it make urine calcium loss worse?

Leila_Khan,_MD: I would take small doses of vitamin D3 to try to get a level closer to 30 while following the urine calcium levels closely. The goal would be to supplement without changing urine calcium concentrations if possible. If this is not possible, living with a vitamin D level less than 30 may be best to prevent additional kidney stones. Otherwise, since you have osteoporosis, I would try some of the bone medications being offered presently such as zoledronic acid, denosomab and others. A hip or spine fracture can be catastrophic and result in significant stays in nursing homes or rehab, and can even lead to death. Please discuss your condition further with your doctor.

sofatax: I have been told that I need to take calcium and vitamin D, but was given no level amounts to take. About 30 years ago, my sister and I were told that we had too much calcium in our blood and so our mother was checked as they already had our grandmother's records (this was all at Mayo Clinic in Rochester, MN). Results show that there are three generations with calcium in the blood. We were told to not have any treatments for this. I now have Celiac disease, thyroid issues and kidney stones with possible heart disease. Mom also now has Sjogren's syndrome in the past month. What treatment plan should I ask my doctor about?

Leila_Khan,_MD: Great question. It sounds like you have a family history of FHH (familial hypercalcemia hypercalciuria), which is a genetic condition that results in high levels of calcium in the blood. It typically does not result in any adverse issues. Surgery and medical treatment are not needed. I’m so sorry to hear that you have celiac disease, thyroid disease and kidney stones; however, this and the Sjogren’s syndrome are likely unrelated to you and your mom having FHH.


Cause and Effect

Pehartman: What are some of the possible root causes of calcium disorders?

Leila_Khan,_MD: There are several disorders, too many to discuss in one response. If you have a particular question about the cause of a specific disorder, we would be happy to answer it.

Jbennett: Can calcium disorders cause loss of energy and depression?

Leila_Khan,_MD: Treatment of vitamin D deficiency can significantly help fatigue and likely also help depression.

Gyndoc84: What is the latest information about the effects of having a low level of D3 or an excessive intake?

Leila_Khan,_MD: Low levels of vitamin D can result in significant loss of bone and potentially also cause a myriad of other symptoms, including fatigue, bone pain and tingling/numbness. I am not familiar with research regarding excessive levels. We are presently not aware of optimal D levels, but usual practice for most endocrinologists is to have a level ranging from 30 to 50 ng/dL.


Osteopenia and Osteoporosis

loveitaly: I was diagnosed with osteopenia below my waist and osteoporosis above my waist. The internal medicine doctor put me on Caltrate, and it gave me very severe constipation, which lasted months. My endocrinologist wants me to use the Prolia injections because he knows my bowels are very sensitive and this won't have to go through the digestive system. I am very sensitive to many medications, and I am concerned that since Prolia is only twice a year, if I happen to be sensitive to it, I will be carrying the side effects for many months. What are the most common side effects of this medication and does it interact with others? (I take quite a few medications, including one that is not FDA approved in the US but has been used for decades in Canada, South America, etc., and it's for vertigo, since I have Meniere's disease). Thanks for your time and expertise.

Susan_Williams,_MD: Per the International Society of Clinical Densitometry guidelines, the lowest bone density measurement from the DXA test is used as the diagnosis. It sounds as though you could benefit from seeing one of us in the Endocrine Calcium Clinic. Although calcium and vitamin D are important for bone health, they cannot treat or reverse osteoporosis. Prolia is an excellent medication for osteoporosis and has very few side effects, but the risk of developing a particular side effect is very individualized and something that needs to be discussed with a physician who knows your medical history well.

clihea2: I have osteoporosis and am not on other medications. I drink two glasses of milk a day. How much calcium by pill should I take? I also take 2000 units of vitamin D.

Leila_Khan,_MD: Each serving of calcium is approximately 300 mg, so your intake of calcium is roughly 600 mg daily. Recommended intake of calcium is approximately 1200 mg/day, so I would take 600 mg of calcium per day to make up this deficiency. 2000 IU vitamin D3 is the usual for patients with vitamin D deficiency, so this dosing is good.

Leahh: Can osteopenia be reversed?

Susan_Williams,_MD: Osteopenia, also known as low bone mass, is a descriptive term and not a diagnosis of a bone disease. For many of us women who are slender Caucasians, having low bone mass is normal and not something that needs to be treated. Having said that, it is important to take good care of your bones at every stage of life, and there is simply no substitute for great nutrition, getting adequate calcium and vitamin D in your diet and having an active lifestyle.

Hummingbird lover: I have developed osteoporosis though my bone density in 2013 was normal. I am 66, so I’m postmenopausal. I had been on HRT from 51 until 55 but stopped once my menopausal symptoms improved. In 2012, I had my sigmoid colon removed and 2" of rectum. I am not a good candidate for oral biphos, as I have had multiple gastric ulcers, including nine at one time in 2013. I take calcium and vitamin D in the recommended doses. I play tennis three or four times per week, so I get lots of weight-bearing exercise. I have been offered Prolia or Reclast for treatment, as my spine bone density is -3.65. I have never been on steroids. I do not like the risk and side effects of either of the above agents, and am concerned about Reclast lasting one year so if I have side effects, they are going to last one year. Do you have any suggestions? My mother had very bad osteoporosis with multiple spinal compression fractures and chronic back pain, and I do not want to go down that road. I have lost 1.5" in height; I am now 5'6" and weigh 150. What are your thoughts?

Leila_Khan,_MD: Great question! Since your mother had severe osteoporosis, you are at risk for this disease too. This is further compounded by the loss of intestine, which can result in a decreased ability of your body to absorb calcium and other vitamins. Without seeing you in person, I can give some general recommendations: I would make sure that your vitamin D is at a good level, and I would have your doctor check your 24-hour urine collection to ensure that the calcium in the urine is also normal and not low. Secondly, I would strongly consider a bone drug because you are going to be at high risk for a fragility fracture given your family history of bone density problems. Despite the negative press, these drugs are extremely safe. Some liken the risk of negative side effects to the risk of being hit by lightning. Getting a spine, hip or forearm fracture can be catastrophic, and I would hate to have you suffer if it is preventable. Check out the front page of the NY Times from the first week of June. They had a nice article about this.


A Matter of Medication

Susan_Williams,_MD: I have a question for our audience this afternoon: How many of you have been prescribed a medication for osteoporosis? If you have been prescribed a medication, are you taking it?

Gyndoc84: None for me.

aaf1031: Yes to prescribed medications, but I’m not taking it due to side effects.

aaf1031: Ibandronate 150mg/monthly due to what I have read. I picked up the prescription.

clihea2: My doctor wanted to put me on Prolia, but decided against it due to my medical history.

Pehartman: Forteo. I’ve been taking it for the past three months.

smartini: Yes, I’m taking Fosamax.

loveitaly: My doctor has suggested the use of Prolia injections, since he knows me very well and says that I would not be able to tolerate Fosamax or other types of oral medications. He is in the process of ordering Prolia, but it hasn't arrived. I am still concerned with possible side effects.

sofatax: I have no prescriptions at the moment.

Gail Ann: I'm not taking any medication as of now. If I needed to be prescribed medication for osteoporosis, what would you suggest? Side effects are a major concern.

Susan_Williams,_MD: It is difficult to recommend one medication over another when I do not know your medical history. Medications such as Fosamax, Actonel and Boniva are all excellent and very safe medications for many patients, but are not for everyone especially individuals with a history of stomach ulcers or certain kidney diseases. Prolia is another very popular option and has very few common side effects. A word of caution is advised here. Certainly if you search Google for any medication, you will see a laundry list of possible side effects. My job as a physician is to get to know each individual patient and be able to estimate the likelihood that that particular patient will or will not experience any of the common or not-so-common side effects.


Closing

That is all the time we have for questions today. Thank you, Dr. Williams and Dr. Khan, for taking time to educate us about calcium disorders.

On behalf of Cleveland Clinic, we want to thank you for attending our online health chat. We hope you found it to be helpful and informative. If you would like to learn more about the benefits of choosing Cleveland Clinic for your health concerns, please visit us online at http://my.clevelandclinic.org.


For Appointments

To make an appointment with an Endocrine Calcium Clinic specialist 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 clevelandclinic.org/endocrinology.

For More Information

About Cleveland Clinic
Cleveland Clinic is a leader in caring for patients with all types of calcium metabolism-related disorders, from the routine to the complex. In our Endocrine Calcium Clinic, patients benefit from access to a multidisciplinary staff, the most advanced technology, and streamlined evaluation and treatment of parathyroid, mineral and bone disorders.

Cleveland Clinic Health Information
Learn more about symptoms, causes, diagnostic tests and treatments for calcium disorders:

Cleveland Clinic Treatment Guide
Calcium & Parathyroid Disorder Treatment Guide
Please use this guide as a resource to learn about calcium disorders and your treatment options. As a patient, you have the right to ask questions and seek a second opinion.

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For additional information about clinical trials, visit: ClinicalTrials.gov.

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