What is the significance of hyperparathyroidism in a 67-year-old female with a history of hypertension (High Blood Pressure), heart disease, high-degree atrioventricular (AV) block, status post pacemaker implantation, Irritable Bowel Syndrome (IBS) with diarrhea-predominance, Gastroesophageal Reflux Disease (GERD), osteoarthritis, rheumatoid arthritis, type 2 diabetes mellitus, and hyperlipidemia?

From the Guidelines

The presence of hyperparathyroidism in this 67-year-old female with multiple comorbidities, including hypertension, heart disease, and type 2 diabetes mellitus, is a significant concern that requires immediate attention, as untreated hyperparathyroidism can worsen her existing cardiovascular disease, contribute to bone loss, and potentially affect her diabetes management. The initial workup should include serum calcium, phosphorus, vitamin D (25-hydroxyvitamin D), albumin, creatinine, and estimated glomerular filtration rate (eGFR) to determine the underlying cause of hyperparathyroidism, which could be primary or secondary due to vitamin D deficiency or renal insufficiency 1.

Key Considerations

• If calcium levels are elevated with the high PTH, this suggests primary hyperparathyroidism, and a parathyroid ultrasound or sestamibi scan should be ordered to locate potential parathyroid adenomas 1.
• If calcium is normal or low with high PTH, this suggests secondary hyperparathyroidism, and vitamin D supplementation may be needed if vitamin D deficiency is confirmed 1.
• Given her multiple comorbidities, renal function assessment is crucial as chronic kidney disease can cause secondary hyperparathyroidism 1.
• A 24-hour urine calcium collection and bone density scan (DEXA) should also be considered to assess for complications of hyperparathyroidism such as nephrolithiasis and osteoporosis 1.

Treatment Options

• Surgical parathyroidectomy is the only curative treatment for primary hyperparathyroidism and is indicated for symptomatic patients and patients with osteoporosis, impaired kidney function, kidney stones, hypercalciuria, and patients ≥ 50 years of age or when calcium has increased to more than 0.25 mmol/L above the upper limit of normal 1.
• Medical therapy, including vitamin D supplementation and phosphate binders, may be used to manage secondary hyperparathyroidism in patients with chronic kidney disease 1.

Importance of Early Intervention

Early diagnosis and treatment of hyperparathyroidism are crucial to prevent long-term complications and improve quality of life 1. Untreated hyperparathyroidism can lead to significant morbidity and mortality, particularly in patients with underlying cardiovascular disease and diabetes mellitus 1. Therefore, it is essential to prioritize the diagnosis and treatment of hyperparathyroidism in this patient to prevent further complications and improve her overall health outcomes.

From the FDA Drug Label

The provided drug labels do not directly address the significance of hyperparathyroidism in a 67-year-old female with a history of hypertension, heart disease, high-degree atrioventricular (AV) block, status post pacemaker implantation, Irritable Bowel Syndrome (IBS) with diarrhea-predominance, Gastroesophageal Reflux Disease (GERD), osteoarthritis, rheumatoid arthritis, type 2 diabetes mellitus, and hyperlipidemia.

The FDA drug label does not answer the question.

From the Research

Significance of Hyperparathyroidism

The significance of hyperparathyroidism in a 67-year-old female with a history of hypertension, heart disease, high-degree atrioventricular (AV) block, status post pacemaker implantation, Irritable Bowel Syndrome (IBS) with diarrhea-predominance, Gastroesophageal Reflux Disease (GERD), osteoarthritis, rheumatoid arthritis, type 2 diabetes mellitus, and hyperlipidemia can be understood through the following points:

• Hyperparathyroidism is a condition where the parathyroid glands are overactive, leading to an excess of parathyroid hormone (PTH) in the body 2, 3, 4, 5.
• Primary hyperparathyroidism, the most common cause of hypercalcemia, can lead to bone disease, nephrolithiasis, or neuromuscular symptoms 2, 3, 4, 5.
• The condition is often asymptomatic, but if symptoms are present, they may include weakness, easy fatigability, anorexia, or anxiety due to hypercalcemia 4.
• Hyperparathyroidism can be diagnosed through a history and physical examination, repeat measurement of serum calcium level, and measurement of creatinine, magnesium, vitamin D, and parathyroid hormone levels 2, 3.

Management and Treatment

The management and treatment of hyperparathyroidism can be summarized as follows:

• The treatment for symptomatic primary hyperparathyroidism is parathyroidectomy, which has success rates of 90 to 95 percent and a low rate of complications when performed by experienced endocrine surgeons 4, 5.
• Asymptomatic patients who decline surgery and meet criteria for medical management must commit to conscientious long-term monitoring of symptoms, serum calcium and creatinine levels, and bone mineral density 2, 3, 4, 5.
• Pharmacological approaches are available and effective for patients who are not candidates for surgery or have concerns about serum calcium or bone mineral density 5.

Considerations for the Patient

Considering the patient's age and medical history, the following points are relevant:

• Primary hyperparathyroidism is most common in postmenopausal women, which is relevant to the patient's demographic 4, 5.
• The patient's history of osteoarthritis and rheumatoid arthritis may be related to the bone disease associated with hyperparathyroidism 2, 3.
• The patient's history of hypertension, heart disease, and high-degree atrioventricular (AV) block may be related to the cardiovascular complications associated with hyperparathyroidism 3.