Bone and Metabolism

The Bone and Metabolism guidelines have been extensively revised. Major changes to the guidelines are listed below.

New topics

Transient thyroid function disorders
Thyroid disorders and pregnancy
Vitamin D supplementation in infants and children
Hypoparathyroidism

Osteoporosis and minimal-trauma fracture

Key updates in Osteoporosis and minimal-trauma fracture management include:

Expanded guidance on Assessment of fracture risk , including discussion and definitions of high and very-high imminent fracture risk.
A new algorithm to guide drug selection after minimal-trauma fracture.
New and expanded guidance on denosumab , including key considerations before starting treatment and the risks associated with discontinuation.
Updated guidance on zoledronic acid, including dose frequency, practice points for safe administration in primary care , and the role of dexamethasone in reducing the severity of an influenza-like reaction.
Expanded guidance on romosozumab and its role in patients at very high risk of fracture.

Vitamin D deficiency

Key updates to Vitamin D defincey in adults include:

Clarification on the role of supplementation in patients at risk of deficiency, and treatment in those with confirmed deficiency.
Clarified treatment regimens based on severity of deficiency.
New treatment regimens for pregnant or breastfeeding adults.

A new topic on Vitamin D supplementation in infants and children outlines:

Which infants and children should be screened for vitamin D deficiency.
Prevention and treatment strategies for vitamin D deficiency and nutritional rickets.
The role of vitamin D supplementation.

Thyroid disorders

Approach to diagnosis of thyroid function disorders

A new diagnostic algorithm for thyroid dysfunction in nonpregnant adults offers investigation pathways to aid diagnosis.
A new table supports subsequent testing for thyroid dysfunction or clinical findings in nonpregnant adults.
A new table discusses the role and interpretation of thyroid antibody-concentration testing.

Transient thyroid function disorders

The new topic Transient thyroid function disorders groups specific new and existing topics by the self-resolving nature of the disorders, including:

Hypothyroidism

The diagnosis and management of hypothyroidism, has been updated, including:

appropriate testing and diagnosis in adults.
A new table on when to start levothyroxine therapy in nonpregnant adults.
Updated drug dosing for Myxoedema coma.

Thyrotoxicosis and hyperthyroidism

Updates to Thyrotoxicosis and hyperthyroidism include:

A simplified summary table of management of primary hyperthyroidism.
More information on adverse effects of antithyroid drugs.
A new table on choice of definitive treatment for primary hyperthyroidism.
Expanded advice on long-term follow up of primary hyperthyroidism.
Expanded advice on specialist use of other treatments for thyrotoxicosis.
Updated and new recommendations for thyroid storm.

Thyroid disorders and pregnancy

Thyroid disorders and pregnancy is a new topic bringing together extensive revisions to:

Three new algorithms provide quick-reference guidance for thyroid function testing preconception, and management of hypothyroidism, and hyperthyroidism during preconception and pregnancy.

Levothyroxine therapy and long-term follow up for thyroid cancer

Levothyroxine therapy and long-term follow up for thyroid cancer has expanded in response to recommendations from international guidelines that primary care practitioners are well-placed to manage long-term follow up of individuals who have been treated for thyroid cancer and are at low risk of recurrence. The topic offers practical advice for primary care practitioners including:

A new figure outlining classification of thyroid cancers and responsiveness to TSH suppression.
A new table on suggested long-term primary care follow up for people who have had thyroid cancer and are in remission.

Adrenal disorders

Adrenal insufficiency: Glucocorticoid replacement during intercurrent illness and surgery

Advice on adjusting glucocorticoid regimens in people with adrenal insufficiency during intercurrent illness and surgery has been expanded and aligned with national and international guidelines. Key updates include:

empirical glucocorticoid regimens for adults and children presented according to illness severity
three new tables outlining perioperative glucocorticoid dosing for people with adrenal insufficiency, presented according to the type of procedure (minor procedures not requiring fasting, general anaesthesia and sedation; and surgical procedures requiring fasting, general anaesthesia and sedation). .

Adrenal crisis

Key updates in managing adrenal crisis are:

an increased emphasis on treating individuals with suspected adrenal crisis immediately in the prehospital setting, then transferring to hospital
glucocorticoid recommendations for suspected adrenal crisis in adults and in children are aligned with national and international guidelines.
intravenous or intramuscular injection of glucocorticoid is preferred for the emergency management of suspected adrenal crisis in adults ; subcutaneous injection, or oral glucocorticoid, may also be used as an interim measure prehospital or before paramedics arrive.
intravenous or intramuscular injection of emergency glucocorticoid is used for children with suspected adrenal crisis
emergency intravenous glucose regimens are included for hypoglycaemia associated with adrenal crisis

Management for adrenal insufficiency during pregnancy and lactation

Advice on adrenal insufficiency during pregnancy and lactation has been expanded, with distinct approaches to management for individuals with pre-existing adrenal insufficiency and new-onset or previously undiagnosed adrenal insufficiency.
Key changes include:

A new figure summarising management for individuals with pre-existing adrenal insufficiency during pregnancy.
A new table describing glucocorticoid dosages recommended for pregnant individuals with adrenal insufficiency during labour and delivery.

Glucocorticoid-induced adrenal insufficiency (adrenocortical suppression)

Glucocorticoid-induced adrenal insufficiency is the new preferred terminology (previously adrenocortical suppression). A comparative table of glucocorticoidd duration of effect has been expanded to include all systemic glucocorticoids used in Australia.

Primary aldosteronism

Key updates to Primary aldosteronism include:

commentary on why targeted, case-based screening for primary aldosteronism continues to be recommended, focused on people with resistant hypertension or suspected secondary hypertension
information on drugs that affect the plasma aldosterone-to-renin concentration ratio has been simplified.

Osilodrostat for Cushing syndrome

Osilodrostat is a new pharmacological treatment for Cushing syndromebut use is limited to specialists.

Phaeochromocytoma and paraganglioma

Paragangliomas are differentiated from phaeochromocytomas as the clinical presentations, investigations and management vary significantly. Management for both requires a specialist and multidisciplinary approach. Information on factors that may cause a false-positive result on metanephrine screening has been simplified. Genetic testing within families, and lifelong surveillance for metastatic disease, are important.

Calcium disorders

Hypocalcaemia

Key updates to Hypocalcaemia include:

serum calcium concentration ranges should be interpreted in the context of clinical presentation, likely aetiology and rate of calcium decrease
administration of intravenous calcium for acute severe hypocalcaemia is complex. For clarity and safety, intravenous calcium regimens are divided into regimens for adults and children.

Hypercalcaemia

Key updates to Hypercalcaemia include:

serum calcium concentration ranges should be interpreted in the context of clinical presentation, likely aetiology, most commonly hyperparathyroidism or hypercalcaemia associated with cancer.
a new table lists causes of hypercalcaemia associated with parathyroid-hormone dependence or independence
a new figure summarises management for adults and children with symptomatic hypercalcaemia
low-dose denosumab is suggested for management of hypercalcaemia in adults with abnormal kidney function, but use is limited to specialists
hypercalcaemia and pregnancy has been expanded to differentiate management for pregnant people with primary hyperparathyroidism from pseudohyperparathyroidism Parathyroid disorders

Parathyroid disorders

Hypoparathyroidism

A new topic has been developed on hypoparathyroidism covering:

the approach to management.
management for chronic hypoparathyroidism in adults.
management considerations during pregnancy.
brief advice on the specialist management of children with hypoparathyroidism.

Hyperparathyroidism

Expanded information on hyperparathyroidism is included covering signs and symptoms, and the role of surgical and pharmacological management.

Hypophosphataemia

Expanded content has been developed to address the different causes of hypophosphataemia:

Pituitary disorders

Chronic hypopituitarism

Updates to Chronic hypopituitarism include:

a new table outlining management of interactions between hormone replacement therapies for chronic hypopituitarism .
a new table summarises the new preferred terms for antidiuretic hormone and diabetes insipidus.
new content on managing chronic hypopituitarism during pregnancy.

Acute hypopituitarism

Expanded content on acute hypopituitarism is included, with:

new advice on investigations.

updated emergency treatment advice for adults and children.

Pituitary apoplexy

Emergency treatment advice for adults with pituitary apoplexy has been updated, including alternative routes of administration, if intravenous access is not possible.

Acromegaly

Updates to Acromegaly include:

updated management advice on treatment targets and the role of surgery, drug therapy and radiation therapy.
new advice on managing comorbidities associated with acromegaly.

Cushing disease

New advice is included on the specialist use of drug therapy for Cushing disease, outlining the role of osilodrostat, metyrapone and ketoconazole.

Hypophysitis

Expanded advice has been developed on hypophysitis , including a new table outlining types and aetiologies of hypophysitis.

Short stature in children

New advice on the specialist management of achondroplasia has been included.

Osteogenesis imperfecta

Osteogenesis imperfecta has been expanded to mention emerging treatment, such as sclerostin-inhibitor therapy. As more people with osteogenesis imperfecta are reaching adulthood, new sections discussing management in adult and during pregnancy have been added.

Osteomalacia

Osteomalacia focusses on management of osteomalacia caused by vitamin D deficiency, given the separate content now available on osteomalacia secondary to chronic kidney disease–mineral and bone disorder

Rickets

Rickets has been updated and expanded to emphasise the differences between nutritional rickets, chronic kidney disease–mineral and bone disorder, hypophosphataemic rickets and vitamin D-dependent rickets types 1 and 2.

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What's New: Bone and Metabolism