What is the best management approach for primary hyperparathyroidism?

From the Guidelines

The best management approach for primary hyperparathyroidism is surgical excision of the abnormally functioning parathyroid tissue, with minimally invasive parathyroidectomy (MIP) being the preferred method when a single adenoma is identified preoperatively, as it conveys the benefits of shorter operating times, faster recovery, and decreased perioperative costs 1.

Key Considerations

• Primary hyperparathyroidism (PHPT) is typically caused by a single parathyroid adenoma (80%) and can also occur from multiple adenomas, parathyroid hyperplasia, or parathyroid carcinoma (<1%) 1.
• Treatment of PHPT is surgical excision of the abnormally functioning parathyroid tissue and is typically indicated even when asymptomatic, given potential negative effects of long-term hypercalcemia 1.
• There are two accepted curative operative strategies for PHPT: bilateral neck exploration (BNE) and minimally invasive parathyroidectomy (MIP), with MIP being less invasive than BNE 1.

Surgical Approach

• MIP requires confident and precise preoperative localization of a single parathyroid adenoma to guide the surgical approach, with intraoperative PTH monitoring used to confirm removal of the hyperfunctioning gland 1.
• BNE is necessary in cases of discordant or nonlocalizing preoperative imaging or when there is high suspicion for multigland disease (MGD) 1.

Postoperative Care

• Persistent PHPT is defined as failure to achieve normocalcemia within 6 months of initial parathyroidectomy, whereas recurrent PHPT is defined as hypercalcemia occurring after a normocalcemic interval of 6 months or more after parathyroidectomy 1.
• Parathyroid reoperations are surgically challenging, with lower cure rates than first-time surgery and higher complication rates, emphasizing the importance of accurate preoperative localization and intraoperative PTH monitoring 1.

From the FDA Drug Label

1.3 Primary Hyperparathyroidism Cinacalcet tablets are indicated for the treatment of hypercalcemia in adult patients with primary HPT for whom parathyroidectomy would be indicated on the basis of serum calcium levels, but who are unable to undergo parathyroidectomy [see Clinical Studies (14.3)]. The best management approach for primary hyperparathyroidism is parathyroidectomy, but for patients who are unable to undergo surgery, cinacalcet can be used to treat hypercalcemia.

• The recommended starting oral dose of cinacalcet tablets is 30 mg twice daily.
• The dose of cinacalcet tablets should be titrated every 2 to 4 weeks through sequential doses of 30 mg twice daily, 60 mg twice daily, and 90 mg twice daily, and 90 mg 3 or 4 times daily as necessary to normalize serum calcium levels 2.
• Serum calcium should be measured within 1 week after initiation or dose adjustment of cinacalcet tablets.
• Patients should be monitored for hypocalcemia, and if serum calcium falls below 7.5 mg/dL, or if symptoms of hypocalcemia persist, withhold administration of cinacalcet tablets until serum calcium levels reach 8 mg/dL and/or symptoms of hypocalcemia have resolved 2.

From the Research

Management Approaches for Primary Hyperparathyroidism

The management of primary hyperparathyroidism (PHPT) can vary depending on the severity of the disease and the presence of symptoms. The following are some of the management approaches for PHPT:

• Surgical removal of the abnormal parathyroid tissue (parathyroidectomy) is the only established treatment for adults with symptomatic PHPT 3, 4.
• Parathyroidectomy is indicated for all symptomatic patients and should be considered for most asymptomatic patients 3.
• The choice of surgery may vary depending on whether the patient has hereditary HPT or thyroid disease requiring surgical treatment, preoperative localization studies, and the findings in these studies 5.
• Cervical ultrasonography or other high-resolution imaging is recommended for operative planning 3.
• Patients with nonlocalizing imaging remain surgical candidates 3.

Non-Surgical Management

For patients who are not surgical candidates or who refuse surgery, non-surgical management options are available:

• Cinacalcet has been shown to decrease serum calcium and parathyroid hormone serum levels in patients with PHPT 6.
• Other treatment options include estrogens, raloxifene, bisphosphonates, and calcitonin 6.
• However, these treatments are not curative and may have varying degrees of effectiveness in managing the symptoms of PHPT.

Comparison of Surgical and Non-Surgical Management

Studies have compared the effectiveness of surgical and non-surgical management of PHPT:

• Parathyroidectomy has been shown to result in a high cure rate for PHPT, with a cure rate of 99% in one study 4.
• Non-surgical management may have little or no effect on serious adverse events or hospitalization for hypercalcaemia 4.
• However, the evidence is very uncertain about the effect of parathyroidectomy on other short-term outcomes, such as bone mineral density, all-cause mortality, and quality of life 4.

Considerations for Management

When considering management options for PHPT, the following factors should be taken into account:

• The presence of symptoms and the severity of the disease 3.
• The results of preoperative localization studies and the findings in these studies 5.
• The patient's overall health and any comorbidities 3.
• The potential risks and benefits of surgical and non-surgical management options 4.