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75 Cards in this Set
- Front
- Back
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When we are looking at the levels of calcium that are in the blood what do you need to compensate for when looking at the levels? |
Amount bound in albumin -> you need to correct for binding |
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What is the effect of acidosis on albumin binding levels? |
There is decreased binding because Ca is ionized (or the protein negative sites are covered) |
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What are the players in the regulation of calcium? |
PTH, Vit D, and Calcitonin |
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What role does magnesium play with calcium? |
It is essential for the release of PTH. |
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The glucocorticoids have what effect on blood calcium? |
They drive it up because of the large bone thinning and osteoclast activation. |
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What is the role of thyroid hormone and growth hormone on the bones? |
Hyper thyroid has large amounts of calcium release. Hypo has disordered bone growth
GH leads to heavy bone growth |
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The parathyroid hormone effects what? |
it increases the amount of serum calcium, magnesium, and vitamin D. |
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Parathyroid release does what to the levels of phosphate that are in the blood stream? |
It depresses the levels of phosphate and drives up the calcium |
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In order to have action from parathyroid, do we need the whole length of the peptide? |
No, we can have the truncated forma. |
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How does PTH effect the levels of calcium in the blood stream? |
It increases it by increasing the levels of 1,25 dihydroxy vit D which is essential to increase the levels of calcium absorption at the intestine -> no effect directly. It acts at the intestine to directly increase the absorption of calcium |
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When you pulse the PTH, what is the overall effect? |
You end up with a drug called forteo which is an effective bone building drug because there is osteoblast stimulation. |
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What is the worry about giving Forteo? |
There is a thought that there might be osteosarcoma risk. |
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What are the side effects that you might see with giving Forteo? |
You might see increased calcium levels which may result in dizziness, nausea, or leg cramping. |
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How do we replace PTH? |
We give natpara which is a synthetic PTH. |
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How does PTH act at the kidney? |
It causes an activation of the 1-alpha hydroxylase which produces activated vitamin D an will increase the amount of tubuluar reabsorption |
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What is the effect of PTH with regard to bicarbonate and the phosphates? |
There is decreased reabsorption in the tubule with the increased Ca absorption. |
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What is the role of the 1,25-dihydroxy? |
It goes to the intestines and it stimulates increased calcium uptake from the intestinal lumen. |
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What is parathyroid hormone related peptide? |
It is a peptide with equal affinity for the PTH receptor that appears to be vital in embryology as well as cancer. It regulates the endochrondral bone growth |
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What happens to PTH levels if you have acute and then chronic hypocalcemia? |
You increase the stimulation from acute preformed release to over production and ultimately cell numberr increase |
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What is calcitonin? |
It is a polypeptide that is made by the parafollicular cells of the thyroid. It is secreted in sensation to high calcium and intestinal peptides. |
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What is the main function of the calcitonin? |
To decrease osteoclastic activity and bring down total blood calcium levels. |
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How would you know if you have had successful treatment of medullary thryoid cancer? |
You should have return to normal calcitonin levels because cancer cells over produce it. |
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What is the treatment of using calcitonin used for? |
It is a nasal therapy but it is modestly effective. It is more often used for its analgesic effects of vertebral pain. |
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What can calcitonin be utilized for? |
It can be given for the purposes of treating pagets and osteosarcoma as well as hypercalcemia. |
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Why is it nice to give calcitonin as an adjunct therapy? |
When injected sub Q there are very few side effects |
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Is it possible to regulate the production of 25-hydroxy vitamin D? |
No, it just happens in the liver. |
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In what case would you have 1,25-dihydroxy vitamin D being over produced in the absence of PTH? |
If you had pregnancy or granulomatous tissue ( as seen in sarcoid) |
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When we measure Vitamin D, what form do we measure in these people? |
We are looking at 25-hydroxy which is the storage form and is in much higher concetration. |
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What would indicate to you that you should get a 1,25-vitamin D? |
If you have hypocalcemia and normal 25-hydroxy, you may want to see if 1,25-dihydroxy is okay. |
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What are the actions of vitamin D? |
It increases the absorption of Ca, phosphate, and mg |
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What is the response to the increasing levels of the vitamin D? |
You have PTH synthesis going down and a decrease in 1-alpha hydroxlase (negative feedback) |
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Where in the intestines does calcium get taken up from? |
From the duodenum. |
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What is the normal reference range of calcium? |
8.5-10.2 mg/dL |
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What is the chvostek test? |
It is a facial nerve test where you tap the facial nerve on one side and the other side of the face twitches |
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What is the Trousseau test? |
It is a test where you inflate a BP cuff around the arm and it induces a claw hand |
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What would you see with hypocalcemia? |
You would find a postive neuromusclar excitability, mental status change, papilledema, increased intracranial pressure, and a lowered seizure threshold. (Among other less obvious changes) |
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If you have low calcium and low PTH, what is the differential? |
Hypoparathyroidism Hypomagnesemia |
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If you have low calcium but normal PTH, what is the differential? |
Literally every other disease |
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Would we think that there is abnormal something going on if you have low PTH chronically? |
Yes, it is indicative of hypoparathyroidism but itf it is temporary it may be indicated by the acute injury to the PTH. |
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What are we thinking when we have impaired PTH secretion? |
DiGeorge Syndrome PTH mutation Sensing mutation for Ca Surgical damage Infiltration (mineral poisoning) |
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If we have autoimmune destruction of the parathyroid, what disease are we looking at what problems might we have? |
DiGeorges |
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What are other causes of low PTH? |
There could be X-ray radiation to the neck damage or there might be genetic cause for it have occurred. |
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What is the best treatment for someone with low calcium? |
Give them activated vitamin D3 and then monitor for kidney stones. |
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What does it mean to have functional hypoparathyroidism? |
You may have a magnesium problem or you might have an issue from trauma during surgery that is temporary. |
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How would you contract hypomagnesemia? |
You could have alcoholism or you might have diarrhea. |
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Good thought process for if you get back a hypocalcemia number is what? |
Next time test for magnesium and vitamin D as well and make sure that those numbers are okay. |
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What are we thinking if there is a high or normal PTH but hypocalemia? |
You might have renal disease or failure and you can't dump the phosphate or vitamin D |
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What is pseudo hypoparathyroidism? |
it is a hereditary form of disease also called Albright Hereditary Osteodystrophy. It is when you have PTH but is non-effective. Many other hormones won't be effective either. |
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What is indicative of AHO? |
Having shortening of the 4/5th metatarsals or metacarpals |
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What is pseudo pseudo hypoparathyroidism? |
It is a condition in which calcium is normal and PTH are normal but you have the same physical deformiites. |
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Vitamin D deficiency shows up as what? |
Shows low calcium absorption from intestine with decreased calcium reabsorption from the bones. |
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What is the disease of the chronic vitamin D deficiency? |
Osteomalacia and rickets |
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What will you seee in someone that has a ricketts type 1 vitamin D activation issue? |
They are going to have renal insufficiency and hyperphosphotemia. |
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Is it common to see type 2 ricketts? |
No, it is rare and it is congenital. The only thing to do with them is give them very high doses of active vitamin D3. |
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Renal failure presents with what facts concerning PTH, calcium, and phosphate? |
They will have high PTH, low calcium, and high phosphate. We need to put the patient onto a low phosphate diet and give them calcium |
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What is the vitamin D drugs end in? |
-ciferol |
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What are the treatments for hypercalcemia? |
Saline volume Loop diruretics Bisphosphonates Phosphates if needed to drive out calcium |
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What is the treatment for hypophosphatemia? |
We need to give phosphate back and preferrably given orally to avoid hypocalcemia (resultant from IV infusion) |
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What is the treatment for hyperphosphatemia? |
Restriction of dietary phosphate Phosphate binders -> Aluminum containing or calcium containing -> calcium can cause hypercalcemia Sevelamer -> good for renal failure
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How do the bisphosphonates work? |
They work by effecting the amount of FPPS that is active which forms lipid essential for osteoclastic function -> inhibition leads to osteoclasts not working so hard |
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What are the 3 most active and effective bisphosphonates? |
Alendronate Risedronate Ibandronate |
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What is the dosing benefit of the bisphosphonates? |
We can give them once daily up to some that wee can just give yearly and then we don't need to retreat again. |
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What are the applications of the bisphosphonates? |
Osteoporosis, hypercalcemia, or Paget's disease |
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What requirements do we have for the administration of bisphosphonates? |
We need them to be taken without any food and the person must remain upright to prevent esophagitis |
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What is the worry about giving bisphosphonates? |
They have potential unusual bone fractures Alternatively, they can cause there to be jaw necrosis -> we need to counsel about dental work |
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What is the role of estrogen in osteoporosis? |
Lack of estrogen (increasingly so after menopause) causes there to be impaired calcium absorption. This leads to hypocalcemia |
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Why don't we just supplement everyone on estrogen? |
There is an increased risk of CVD in women. But when we do there is better calcium levels and osteoclasts are better managed. |
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So what are the benefits to the usage of estrogen and progestin therapy? |
There is better success of colorectal cancer reduction and hip fractures |
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What do we use HRT for? |
The treatment of menopause signs |
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What are scary side effects of estrogen treatment? |
There are problems with hypertension, breast cancer, and thromboembolic disease |
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What are the danger signs of estrogen use that we should be aware of? |
Abnormal vaginal bleeding Pain in calf/chest Shortness of breath Coughing blood Breast lump Severe headaches VIsion changes |
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Better than estrogen replacement is what? |
Selective estrogen receptor modifiers |
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what is the fxn of the SERM? |
They modulate the effects of estrogens that are made naturally by the body but do not increase the risk of breast or uterine cancers.
The SERM may in fact reduce the chances of breast cancer |
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What is the name of the SERM that wee use for the treatment of osteoporosis? |
Raloxifene -> it is good for those women who are at high risk for breast cancer or those postmenopausal women that have osteoporosis |
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What side effects might you get from using SERMS? |
You might see hot flashes, leg cramps, or GI distress (probably from calcium retention) |
