PTH-Guided Calcium Supplementation Matches Routine Therapy for Preventing Hypocalcemia After Thyroidectomy: Study
Colombia: Researchers have found in a randomized trial that routine blanket calcium supplementation after total thyroidectomy offers no added benefit over a selective, parathyroid hormone (PTH)–guided approach in preventing postoperative hypocalcemia. The PTH-guided strategy safely reduced unnecessary calcium supplementation without increasing adverse events. Both strategies were equally effective, and the choice may depend on the availability of rapid PTH assays and surgeon preference.
Postoperative hypocalcemia remains the most common complication following total thyroidectomy, often prompting surgeons to prescribe prophylactic calcium and calcitriol (C+C) to all patients. However, some clinicians advocate a more targeted strategy, using early postoperative PTH levels to identify those at genuine risk.
To clarify the optimal approach, Carlos Garcia-Lozano from the Head and Neck Service, Department of Surgery, School of Medicine, Universidad de Antioquia, Medellín, Colombia, and colleagues conducted a multicenter, pragmatic randomized clinical trial comparing routine supplementation with a selective, PTH-guided strategy. The findings were published in JAMA Otolaryngology–Head & Neck Surgery.
The trial was conducted across three tertiary hospitals from June 1, 2022, to July 31, 2024. Adult patients undergoing total thyroidectomy for either benign or malignant thyroid disease were eligible. Individuals with a history of parathyroid surgery or known disorders of calcium metabolism were excluded. Data analysis was completed between October 2024 and March 2025.
Participants were randomly assigned to one of two groups. In the selective group, supplementation with calcium and calcitriol was initiated only if the 4-hour postoperative PTH level was below 15 pg/mL. In contrast, the routine group received prophylactic calcium and calcitriol for 15 days after surgery, regardless of PTH levels. The primary endpoint was the development of symptomatic hypocalcemia within 15 days, assessed using a standardized symptom scale. Secondary outcomes included biochemical hypocalcemia, adverse events, need for additional calcium supplementation, and hospital readmissions.
Key findings were as follows:
- The analysis included 258 patients, with 117 assigned to the PTH-guided group and 141 to the routine supplementation group.
- The mean age of participants was around 50 years, and more than 80% were women.
- Nearly half of the patients in both groups had Bethesda category III to VI nodules.
- Symptomatic hypocalcemia developed in 9.3% of patients overall.
- The incidence of symptomatic hypocalcemia was 7.8% in the PTH-guided group and 11.1% in the routine supplementation group, with no statistically significant difference between them.
- Rates of biochemical hypocalcemia were comparable between the two groups, with no meaningful difference observed.
- Adverse events and postoperative complications were similar in both strategies.
- Patients in the PTH-guided group required less overall calcium supplementation, suggesting reduced overtreatment.
The investigators concluded that selective supplementation based on early postoperative PTH levels was not superior to routine prophylactic therapy in preventing either symptomatic or biochemical hypocalcemia. Both strategies appear safe and effective, allowing clinicians to tailor their approach according to institutional resources, access to rapid PTH testing, and clinical judgment.
Reference:
Garcia-Lozano C, Betancourt C, Sanchez JG, et al. Routine vs Selective Calcium Supplementation After Total Thyroidectomy: A Randomized Clinical Trial. JAMA Otolaryngol Head Neck Surg. Published online February 19, 2026. doi:10.1001/jamaoto.2025.5514
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