Internal Medicine

0521779407-16 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:18

1102 Osteomalacia and Rickets

specific therapy

Indications

■Rickets, hypocalcemia, hypophosphatemia, fractures, growth retar-

dation, muscle weakness or pain

Treatment Options

■Nutritional rickets: vitamin D and calcium

■Hypocalcemic rickets: calcium and vitamin D

■Hypophosphatemic rickets: phosphate and vitamin D

■Renal failure and 1-alpha-hydroxylase deficiency: calcitriol, phos-

phate binders to reduce hyperphosphatemia

■HVDRR: high-dose calcium and calcitriol; may require IV infusions

of calcium

■Oncogenic osteomalacia: removal of offending tumor

Side Effects

■Excessive replacement of calcium and vitamin D: hypercalcemia,

hypercalciuria, renal stones

■Excessive vitamin D or calcitriol: hypervitaminosis D

■Excessive oral phosphate: diarrhea

follow-up

During Treatment

■Monitor calcium and phosphate, observe vitamin D and PTH levels

■Assess symptom reduction

■Assess fracture healing

■Adults: monitor bone mineral density

■Intermittently check bone x-rays for evidence of healing of rickets

Routine

■Monitor growth

■Observe family members for hereditary syndromes

complications and prognosis

■Nutritional rickets responds well to vitamin D and calcium

■Renal osteodystrophy dramatically improved by preventing hyper-

phosphatemia and secondary hyperparathyroidism with calcitriol

■Oncogenic osteomalacia responds dramatically to tumor removal;

patients should be observed for recurrence of syndrome, implying

tumor recurrence

■Hereditary syndromes show improvement in rickets if calcium,

phosphate and vitamin D can be normalized; healing of rickets can