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To the Editor: In the Clinical Crossroads discussing a patient with primary hyperparathyroidism, Dr Strewler¹ did not mention the intake of thiazide diuretics in the differential diagnosis of hypercalcemia. This is particularly important in cases of suspected primary hyperparathyroidism in which thiazide therapy may have an impact on disease management.

Thiazide diuretics can increase serum calcium levels by complex mechanisms that include a decrease in urinary calcium excretion,^2-3 enhancement of parathyroid hormone action,^2-3 and possibly an increase in intestinal calcium absorption and bone resorption.⁴ In healthy persons with normal calcium homeostasis, the increase in serum calcium with thiazide intake is generally mild and transient, in the range of 0.5 to 1 mg/dL (0.12-0.25 mmol/L), lasting 4 to 6 weeks.^3-4 However, in patients with underlying hyperparathyroidism, thiazide use typically uncovers or aggravates the hypercalcemia.^{3, 5} In this setting, overestimation of hypercalcemia as a result of thiazide intake may lead to unnecessary patient . . . [Full Text of this Article]

Nasser Mikhail, MD, MSc
nmikhail@ladhs.org
Department of Endocrinology

Dennis Cope, MD
Department of Medicine
Olive View-UCLA Medical Center
Sylmar, Calif

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