Curriculum standards
Knowledge guides
LG 21: Parathyroid, calcium and bone disorders
Key presentations and conditions
Advanced Trainees will have a comprehensive depth of knowledge of these presentations and conditions.
Less common or more complex presentations and conditions
Advanced Trainees will understand these presentations and conditions.
Advanced Trainees will understand the resources that should be used to help manage patients with these presentations and conditions.
Epidemiology, pathophysiology, and clinical sciences
Advanced Trainees will have a comprehensive depth of knowledge of the principles of the foundational sciences.
Investigations, procedures, and clinical assessment tools
Advanced Trainees will know the scientific foundation of each investigation and procedure, including relevant anatomy and physiology. They will be able to interpret the reported results of each investigation or procedure.
Advanced Trainees will know how to explain the investigation or procedure to patients, families, and carers, and be able to explain procedural risk and obtain informed consent where applicable.
Important specific issues
Advanced Trainees will identify important specialty-specific issues and the impact of these on diagnosis and management, and integrate these into care.
Presentations
- Abdominal pain
- Altered cognition
- Asymptomatic with incidental findings
- Bone pain
- Cardiac arrythmias
- Constipation
- CKD-MBD
- Fractures
- Nausea or vomiting
- Numbness of hands, feet, mouth
- Preventative in hormone deprivation therapy for breast or prostate cancer
- Renal stones
- Tetany and/or cramping
Conditions
- Hormone deprivation therapy for breast or prostate cancer
- Hyperparathyroidism:
- medication-induced
- normocalcaemic
- primary
- secondary
- tertiary
- Hypocalcaemia:
- hypoparathyroidism:
- congenital
- idiopathic
- infiltrative
- post-surgical
- vitamin D deficiency
- hypoparathyroidism:
- Hypophosphatasia
- Pseudohypoparathyroidism:
- autosomal dominant hypocalcaemia (calcium -sensing receptor mutations)
- medication-induced
- vitamin D receptor mutations
- PTH-independent hypercalcaemia:
- malignancy-associated
- milk-alkali syndrome
- sarcoidosis
- Osteomalacia
- Osteopenia
- Osteoporosis
- Paget’s disease
- Vitamin D deficiency
For each presentation and condition, Advanced Trainees will know how to:
Synthesise
- recognise the clinical presentation
- identify relevant epidemiology, prevalence, pathophysiology, and clinical science
- take a comprehensive clinical history
- conduct an appropriate examination
- establish a differential diagnosis
- plan and arrange appropriate investigations
- consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
- provide evidence-based management
- prescribe therapies tailored to patients' needs and conditions
- recognise potential complications of disease and its management, and initiate preventative strategies
- involve multidisciplinary teams
Consider other factors
- identify individual and social factors and the impact of these on diagnosis and management
Presentations
- First presentation of hypercalcaemia in pregnancy
Conditions
- Complications of osteoporosis therapies, atypical femur fractures and medication-related osteonecrosis of the jaw
-
Disorder of high bone mass:
- acquired
- inherited
-
Hyperparathyroidism due to underlying genetic disorder:
- familial hypocalciuric hypercalcaemia
- familial isolated idiopathic hyperparathyroidism
- hyperparathyroidism-jaw tumour syndrome
- MEN1
- MEN2A
-
Hypophosphataemia:
- acquired
- inherited, including x-linked
-
Inherited disorders of skeletal dysplasia:
- fibrous dysplasia
- hyperostosis
- osteogenesis imperfecta
- Parathyroid cancer
- Pregnancy-related conditions including transient osteoporosis of the hip and lactation-related osteoporosis
For each presentation and condition, Advanced Trainees will know how to:
Synthesise
- recognise the clinical presentation
- identify relevant epidemiology, prevalence, pathophysiology, and clinical science
- take a comprehensive clinical history
- conduct an appropriate examination
- establish a differential diagnosis
- plan and arrange appropriate investigations
- consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
- provide evidence-based management
- prescribe therapies tailored to patients' needs and conditions
- recognise potential complications of disease and its management, and initiate preventative strategies
- involve multidisciplinary teams
Consider other factors
- identify individual and social factors and the impact of these on diagnosis and management
Inherited disorders/Disorders with a genetic basis
- Incidence and prevalence of conditions in Australian population
- Recognise and screen for the possibility of known genetic variants causing pathology
- Referral for genetic counselling, wherever needed
- Screening for associated pathology in known inherited disorders
- Screening of family members, when indicated
Osteoporosis screening
- Counsel patients with up-to-date best practice guidelines for nutritional lifestyle and exercise recommendations
- Identify risk factors for poor bone health
- Perform a fracture risk assessment using a validated fracture risk calculator (e.g. FRAX or Garvan tool)
- Population-based screening
- Provision of preventative care against osteoporosis
- Screening for secondary osteoporosis, such as:
- glucocorticoid treatment, Cushing syndrome
- hypogonadism, androgen deprivation
- malabsorption
- premature menopause
- systemic mastocytosis
Therapeutics
- Appropriate prescribing of nutritional therapy and physical activity
- Prescribe anti-resorptive and anabolic bone medications according to best practice, employing an individualised approach
- Hyperparathyroidism management with medical therapies
- Emergent management of severe or symptomatic hypercalcaemia
- Emergent management of severe or symptomatic hypocalcaemia:
- assessment and management of concomitant magnesium deficiency
- understand and interpret severity, including monitoring ECG changes
- Prescribing for rickets and osteomalacia
- Take preventative action to avoid or mitigate risk of adverse events from available pharmaceutical agents
Clinical assessment
- Assessment of nutrition and physical activity, screening for restrictive eating and overexercise, identifying and modifying risk factors for falls (where appropriate)
- FRAX
- Identify and refer patients for surgery where appropriate:
- triage patients with indications for surgical intervention according to condition severity
- Monitoring disease activity
- Monitoring response to therapy
- Provide perioperative care:
- long term management of post-surgical hypoparathyroidism and serum calcium management with calcitriol (to avoid nephrocalcinosis/hypercalciuria)
- patients undergoing parathyroid surgery
- patients with hypocalcaemia
- Review medications (including over-the-counter and non-prescription agents) for drug-drug and drug-disease interactions
Imaging
- Bone mineral density (and its limitations)
- Bone scintigraphy
- Localisation of parathyroid adenoma/cancer:
- 4D CT
- neck U/S
- nuclear medicine parathyroid scan
- Plain radiographs (e.g. identify and quantify vertebral fractures on thoracolumbar spine radiographs)
- Trabecular bone score, vertebral fracture assessment
Laboratory tests
- 1,25-dihydroxyvitamin D
- 24-hour or spot fasting urine collections for calcium, creatinine, and phosphate, with calculation of TmP/GFR and calcium/creatinine ratio
- 25-hydroxyvitamin D
- Bone-specific ALP
- Bone turnover markers
- Calcium (corrected and ionised)
- Electrolytes
- FGF-23
- iPTH, PTHrp
- Kidney function
- LFT
- Magnesium
- Phosphate
- Screening for:
- nutritional deficits, including:
- albumin
- electrolytes
- serum protein
- secondary causes of osteoporosis, including:
- coeliac disease
- hypogonadism
- multiple myeloma
- TFTs
- vitamin D deficiency
- nutritional deficits, including:
- Tmp/GFR
Evidence-based practice
- Remain abreast of evidence for best practice and apply this using clinical judgement and individual circumstances in partnership with patients
Management considerations
- Conception counselling
- Conservative management where able and individualised care
- Genetic counselling
- Incorporate environmentally sustainable practices in clinical care
- Pregnancy management:
- first presentation of hypercalcaemia in pregnancy
- pre-existing hyperparathyroidism
- pre-existing hypocalcaemia
- pre-existing osteoporosis, including discussion of the duration of lactation
- Osteoporosis considerations:
- intermittent secondary amenorrhoea
- malabsorption and lactose intolerance symptoms
- over exercise
- restrictive eating, including meat/protein and dairy avoidance
- underweight