SUN-376 A Quality Improvement Project on Identification and Management of Primary Hyperparathyroidism in Patients Who Present with Osteoporosis to Reduce Morbidity from Bone Disease

Abstract

Introduction:Individuals with Primary Hyperparathyroidism (PHPT); a common endocrine disorder are at increased risk of both vertebral and peripheral fractures.Meanwhile Normocalcaemic Primary Hyperparathyroidism (NPHPT),a recognised phenotype of PHPT with a prevalence of 0.4-3.1% in community-based cohorts were anticipated to be milder but most case series documented high rates of osteoporosis, fractures and kidney stones.Objective:We proactively evaluated patients with a new diagnosis of osteoporosis to (a) identify the frequency of hypercalcaemic and normocalcaemic primary hyperparathyroidism in this cohort of patients and (b) to evaluate the benefit of deploying a proactive process for this evaluation as compared to the current arrangement in our Centre of devolving this to the primary care team.Method:This cross-sectional study evaluated 194 patients whom were referred for dexa scan for newly diagnosed osteoporosis between January 2018 and December 2018. Patients whom had a secondary causes of osteoporosis, eGFR<60mls/min, liver and malabsorptive conditions and taking medications that would interfere with bone metabolism were excluded from the study. A recommendation letter was sent to them and their General Practitioner to undertake the following investigations: serum calcium, PTH, phosphate, vitamin D, magnesium, liver function test, full blood count, coeliac screen and thyroid function test. Abnormal blood tests including new diagnosis of primary hyperparathyroidism and vitamin D deficiency were identified and treated accordingly. A second letter and telephone calls were made as a reminder if no response were received within 12 weeks of the first letter.Results:After the first letter, only 83 (34.3%) patients complied with the request for the blood tests. After another 3 months a further 86 patients had the test done while 25(12.9%) did not have the test done despite the reminder.Mean age was 69.72 ± 13.01 and 90.2% were females. The commonest indication for bone density assessment was fragility fracture (46.2%). 69 (35.6%) had spinal, 77 (39.7%) femoral and 9 (4.6%%) wrist osteoporosis. 17(8.8%) patients were detected to have hypercalcaemic and 8(4.73%) patients had normocalcaemic primary hyperparathyroidism. 18(10.7%) patients had vitamin D deficiency and secondary PHPT with half of these patients (9(5.3%)) had severe deficiency (<25 nmol/L).Conclusions:A significant proportion of patients with osteoporosis without prior history of metabolic bone disease had PHPT but the proportion of these having NPHPT is low unlike what is reported in the literature.Proactive assessment of secondary causes is much more effective and should be routinely deployed