How are osteoporosis and osteopenia treated in patients with hypercalciuria?

Updated: Apr 23, 2019
  • Author: Stephen W Leslie, MD, FACS; Chief Editor: Vecihi Batuman, MD, FASN  more...
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Answer

The issue of hypercalciuria treatment can be complicated by the presence of osteoporosis or osteopenia. A serum calcium determination is the first step in identifying patients with possible hyperparathyroidism. The identification of elevated serum calcium levels should be followed up with a simultaneous PTH level to diagnose hyperparathyroidism.

Even without a history of calcium kidney stones, a 24-hour urine test to check urinary calcium excretion can be useful in the management of osteoporosis. If the patient has hypercalciuria (and hyperparathyroidism has been eliminated by serum testing), the patient will benefit from thiazide therapy, which increases serum calcium and reduces excessive urinary calcium excretion.

Estrogen should be used, if appropriate, in postmenopausal women. Bisphosphonates, such as alendronate (Fosamax), risedronate (Actonel), or ibandronate (Boniva), should be used in men and in women when estrogen cannot be used.

Calcium supplementation can be helpful in osteoporosis, but urinary calcium levels need to be monitored carefully in calcium stone–forming patients, especially if they demonstrate overt hypercalciuria.

Studies have shown that, for most postmenopausal women with osteoporosis but with no previous history of calcium kidney stone disease, the overall risk of calcium nephrolithiasis does not increase significantly with the use of supplemental calcium or of combined calcium with calcitriol, despite an increase in urinary calcium excretion. [24]

Calcium citrate is recommended for calcium-stone formers in this situation, because its citrate component limits any increase in stone formation rate. Medical therapy, including thiazides, should be started first; calcium citrate can then be added until the urinary calcium level reaches the normal upper limit (250 mg of calcium per 24 hours or 4 mg of calcium per kilogram of body weight).

Other treatment for possible urinary stone risk factors, such as uric acid, citrate, volume, phosphate, sodium, magnesium, and oxalate, should be optimized.


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