A symptom-based algorithm for calcium management after thyroid surgery: a prospective multi-center study.

Abstract

Evidence based treatment guidelines for the management of post-thyroidectomy hypocalcemia are absent. The aim of this study was to evaluate a newly developed symptom-based treatment algorithm including a protocolized attempt to phase out supplementation. In a prospective multicenter study, patients were treated according to the new algorithm and compared to a historical cohort of patients treated with a biochemically-based approach. The primary outcome was the proportion of patients receiving calcium and/or alphacalcidol supplementation. Secondary outcomes were calcium-related complications and predictors for supplementation. 134 patients were included prospectively, and compared to 392 historical patients. The new algorithm significantly reduced the proportion of patients treated with calcium and/or alphacalcidol during the first postoperative year (OR 0.36 [95% CI 0.23 - 0.54], p<0.001), and persistently at 12 months follow-up (OR 0.51 [0.28 - 0.90], p<0.05). No severe calcium-related complications occurred, even though calcium-related visits to the emergency department and readmissions increased (OR 11.5 [4.51 - 29.3], p<0.001) and (OR 3.46 [1.58 - 7.57], p<0.05), respectively. The proportional change in pre- to postoperative parathyroid hormone (PTH) was an independent predictor for supplementation (OR 1.04 [1.02 - 1.07], p<0.05). Symptom-based management of post-thyroidectomy hypocalcemia and a protocolized attempt to phase out supplementation safely reduced the proportion of patients receiving supplementation, although the number of calcium-related hospital visits increased. For the future, we envision a more individualized treatment approach for patients at risk for delayed symptomatic hypocalcemia, including the proportional change in pre- to postoperative PTH.