hyperparathyroïdie primitive: atteinte osseuse et ... · 2003: hyperparathyroïdie primitive...
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Hyperparathyroïdie primitive: Atteinte osseuse et stratégies de prise en charge
Pascal Houillier Département de Physiologie Université Paris-Descartes
Hôpital Européen Georges Pompidou INSERM U872, CNRS ERL7226
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Déclaration d’intérêt
Activités de consultant, subventions de recherche :
Amgen
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1948 : Primary hyperparathyroidism
« A state of increased parathyroid hormone secretion, inappropriate to the prevailing
hypercalcemia » (Albright, 1948)
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1991: Hyperparathyroïdie primitive asymptomatique
• Diagnos is and Management of A s y m p t o m a t i c P r i m a r y Hyperparathyroidism: Consensus Development Conference Statement
Ann Intern Med. 1 April 1991;114(7):593-597
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2003: Hyperparathyroïdie primitive normocalcémique
« Recently, another variant of PHPT (normocalcaemic PHPT) has been described in which the serum calcium is normal but the serum PTH is elevated, in the absence of any secondary cause for PTH elevation. »
J. Bilezikian J Intern Med. 2005;257(1):6-17
J Clin Endocrinol. Metab. 2003; 88: 4641
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Comparaison de 2 groupes d’hyperparathyroïdie primitive normo et hypercalcémiques
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Atteinte osseuse
S Silverberg et al, J Bone Miner Res, 1989
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D.W. Dempster , et al, Bone 2007
Preserved three-dimensional cancellous bone structure in mild primary
hyperparathyroidism
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D.W. Dempster , et al, Bone 2007
Preserved three-dimensional cancellous bone structure in mild primary
hyperparathyroidism
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BMD in patients with normocalcemic PHPT.
Lowe H et al. JCEM 2007;92:3001-3005
©2007 by Endocrine Society
T-Score by site
% of osteoporosis
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Effect of Primary Hyperparathyroidism on Volumetric Bone Mineral Density and
Bone Geometry (pQCT)
Charopoulos et al, J Clin Endocrinol Metab, 2006
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Evolution osseuse
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Mean (±SE) Change in Bone Mineral Density at Three Sites in Patients with Primary Hyperparathyroidism,
According to Treatment.
Silverberg SJ et al. N Engl J Med 1999;341:1249-1255.
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Biochemical Values in 52 Asymptomatic Patients with Primary Hyperparathyroidism Who Did Not Undergo
Parathyroidectomy.
Silverberg SJ et al. N Engl J Med 1999;341:1249-1255.
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Evolution après le diagnostic des formes normocalcémiques
H Lowe et al, J Clin Endocrinol Metab, 2007
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Risque fracturaire
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Primary Hyperparathyroidism and the Risk of Fracture: A Population-Based
Study
Journal of Bone and Mineral Research 1999
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Primary Hyperparathyroidism and the Risk of Fracture: A Population-Based
Study
Journal of Bone and Mineral Research 1999
Vertebrae Colles
Rib Any
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Recommandations pour le traitement chirurgical de l’hyperparathyroïdie
primitive asymptomatique
Recommandations NIH (2002)
Recommandations NIH (2008)
Calcémie (au delà de la limite supérieure de la normale)
0,25 mmol/L 0,25 mmol/L (10 mg/L)
Calciurie (24 h) > 10 mmol/24 h Pas de recommandation
Clearance de créatinine (DFG)
Diminuée de 30 % < 60 mL/min
Densité minérale osseuse
T-score < -2,5 T-score < -2,5
Age < 50 ans < 50 ans
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Copyright ©2004 The Endocrine Society Khan, A. A. et al. J Clin Endocrinol Metab 2004;89:3319-3325
Effect of alendronate on lumbar spine (A), total hip (B), femoral neck (C), and one third distal radius (D) BMD
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Copyright ©2005 The Endocrine Society
Peacock, M. et al. J Clin Endocrinol Metab 2005;90:135-141
Comparison of predose serum calcium concentrations
in patients receiving cinacalcet or placebo
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Treatment by cinacalcet is not a chemical parathyroidectomy
Peacock, M. et al. J Clin Endocrinol Metab 2009
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Cas particulier de l’HPTP normocalcémique
• Pas de recommendation consensuelle • Absence de restriction des apports calciques • Maintien d’un capital en vitamine D normal (>75 nmol/L ; 30 ng/mL) • Œstrogènes ? • Raloxifène ? • Bisphosphonates • PAS DE Calcimimétique
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Conclusion • Atteinte osseuse fréquente dans
les formes asymptomatiques • Augmentation du risque
fracturaire • Préservation de l’os trabéculaire :
est-ce un mythe ? • Squelette axial vs. périphérique • DXA vs. pQCT
• Atteinte osseuse réversible après chirurgie
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Relation normale et intervalle de confiance à 95 %
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Effet du test de charge orale en calcium