What is the recommended treatment for primary hyperparathyroidism?

Treatment of Primary Hyperparathyroidism

Parathyroidectomy is the definitive treatment for primary hyperparathyroidism and should be recommended for virtually all patients with this condition. 1, 2

Surgical Management

Parathyroidectomy is the treatment of choice for primary hyperparathyroidism for several reasons:

• 80-85% of cases are caused by a solitary parathyroid adenoma 2
• Surgery provides definitive cure with high success rates
• Two accepted surgical approaches 1:
  • Bilateral neck exploration (BNE)
  • Minimally invasive parathyroidectomy (MIP)

Surgical Indications

While the National Institutes of Health previously published more limited criteria for surgery, current evidence supports surgical intervention for most patients due to:

• Improved quality of life measures
• Reduced risk of renal calculi
• Improved bone density
• Better cardiovascular health
• Reduced mortality risk 2

Surgical Considerations

• Referral to a high-volume parathyroid surgeon is recommended for optimal outcomes 1
• Preoperative localization studies and intraoperative PTH assays have enabled more focused surgical approaches 2
• Potential complications include:
  • Severe hypocalcemia (hungry bone syndrome) - up to 36.2% of cases
  • Hypercalcemia - approximately 24.6% of cases
  • Permanent hypoparathyroidism
  • Recurrence or persistence of hyperparathyroidism 1

Medical Management

For patients who cannot or do not want to undergo surgery, medical management options are available:

Cinacalcet

• FDA-approved for primary hyperparathyroidism in patients who cannot undergo parathyroidectomy 3
• Starting dose: 30 mg twice daily
• Titrate every 2-4 weeks through sequential doses (30 mg twice daily, 60 mg twice daily, 90 mg twice daily, and 90 mg 3-4 times daily) as needed to normalize calcium levels 3
• Effectively reduces serum calcium but has only modest effects on PTH levels and does not improve bone mineral density 4
• Monitor serum calcium every 2 months once maintenance dose is established 3

Bisphosphonates

• Recommended to improve bone mineral density in patients with primary hyperparathyroidism 4
• Alendronate has the best evidence, improving BMD at the lumbar spine without altering serum calcium 4

Combination Therapy

• Combined cinacalcet and bisphosphonate therapy may be reasonable to both reduce serum calcium and improve BMD, though strong evidence for this approach is limited 4

Calcium and Vitamin D Management

• Calcium intake should follow general population guidelines; restriction is not recommended 4
• Vitamin D repletion is recommended for patients with low 25-hydroxyvitamin D levels:
  • Minimum goal: ≥50 nmol/L (20 ng/mL)
  • Reasonable goal: ≥75 nmol/L (30 ng/mL) 4
• Monitor vitamin D status to avoid deficiency, which can affect PTH levels 1

Predictive Testing for Surgical Outcomes

Short-term medical treatment with calcimimetics before surgery can help predict symptomatic response to parathyroidectomy, with positive predictive values of 74-96% 5. This approach may aid in surgical decision-making for patients with non-specific symptoms.

Management of Severe Hypercalcemia

For patients presenting with severe hypercalcemia (calcium ≥14 mg/dL):

1. Initial stabilization with hydration (IV saline)
2. Furosemide diuresis
3. Consider bisphosphonates or denosumab for severe cases 6, 7
4. Proceed to parathyroidectomy once calcium levels are reduced to safer levels (<12 mg/dL) 7

This approach has demonstrated high success rates, with studies showing nearly all patients can survive with proper management 7.