During the pandemic, pre-treatment calcium checks are:
- essential for patients at high risk of hypocalcaemia
- recommended for patients at low risk of hypocalcaemia, wherever possible.
It's important to:
- treat patients individually, based on the criteria below
- consider patients' feelings around visiting health care settings.
Local facilities may be available for minimal contact blood tests. For example:
- Domiciliary phlebotomy
- Drive-through service.
High risk patients
High-risk patients are those that have CKD 3b or worse.
- Should be managed within or in conjunction with secondary care services
- Require the pre-treatment calcium check
- In many cases, also require post-treatment blood monitoring
- Are unlikely to benefit from higher doses of colecalciferol (because of the inability to undertake renal hydroxylation of 25(OH)-vitamin D to the active form)
- Have previously received treatment with denosumab on two or more occasions without clinical or biochemical evidence of hypocalcaemia pre- or post-treatment
- Are taking their usual calcium or vitamin D supplements regularly
- Have adequate and stable renal function, ie. CKD G1-3a
- Have no new comorbidities or medications since previous injection that are likely to affect renal function or calcium handling
We recommend that these patients still have their check as services start to reopen. Future spikes in the pandemic may affect future opportunities for checks.
If the pre-treatment blood test is omitted, apply these precautions to reduce risk of hypocalcaemia:
- Ensure dietary and supplemental calcium equates to at least 1000mg a day
- Ensure the patient takes at least 800IU colecalciferol a day (a higher dose may be needed in obese patients)
- An additional bolus of oral vitamin D a week, or two prior to injection e.g. oral colecalciferol 20,000IU
- Where feasible, a blood sample to check calcium and creatinine, at the time of injection