What are the treatment options for hyperparathyroidism?

Treatment Options for Hyperparathyroidism

Surgical intervention is the definitive treatment for primary hyperparathyroidism, while secondary hyperparathyroidism requires a stepwise approach starting with medical management and progressing to surgery for refractory cases. 1

Primary Hyperparathyroidism

Surgical Management

• Parathyroidectomy is the standard of care for all symptomatic patients with primary hyperparathyroidism and should be considered for most asymptomatic patients 2
• Surgery is more cost-effective than observation or pharmacologic therapy for primary hyperparathyroidism 2
• Two effective surgical approaches are available:
  • Minimally invasive parathyroidectomy (MIP): A focused, image-guided unilateral operation with limited dissection for targeted removal of only the affected gland 1
  • Bilateral neck exploration (BNE): Traditional approach where all parathyroid glands are identified and examined, with removal of diseased glands 1
• MIP offers benefits of shorter operating times, faster recovery, and decreased perioperative costs compared to BNE 1
• MIP requires confident preoperative localization of a single parathyroid adenoma and intraoperative PTH monitoring 1
• BNE remains necessary for cases with discordant/nonlocalizing imaging or suspected multigland disease 1

Preoperative Considerations

• Preoperative imaging is essential to localize abnormal parathyroid tissue:
  • Cervical ultrasonography or other high-resolution imaging is recommended 2
  • 99Tc-Sestamibi scan may be used, especially for reoperative cases 1
  • Patients with nonlocalizing imaging remain surgical candidates 2
• Preoperative parathyroid biopsy should be avoided 2
• Patients with hypercalcemia and PTH levels ≤50 pg/mL should still be considered for parathyroidectomy as they have similar outcomes to other primary hyperparathyroidism patients 3

Special Considerations

• Surgeons who perform a high volume of parathyroidectomies have better outcomes 2
• Devascularized normal parathyroid tissue should be autotransplanted 2
• Familial primary hyperparathyroidism, reoperative parathyroidectomy, and parathyroid carcinoma require special expertise 2

Secondary Hyperparathyroidism

Medical Management

• Initial treatment includes:
  • Dietary phosphate restriction 1
  • Phosphate binders 1
  • Correction of hypocalcemia 1
  • Vitamin D sterols 1
• For persistent secondary hyperparathyroidism despite above measures:
  • Calcimimetics (cinacalcet) may be considered 1
  • Cinacalcet is FDA-approved for secondary hyperparathyroidism in adult patients with chronic kidney disease on dialysis 4
  • Caution: Cinacalcet should be used carefully as it has been associated with hypocalcemia and increased QT interval 1

Surgical Management

• Parathyroidectomy should be recommended for severe hyperparathyroidism (persistent serum levels of intact PTH >800 pg/mL) associated with hypercalcemia and/or hyperphosphatemia refractory to medical therapy 1
• Effective surgical options include:
  • Subtotal parathyroidectomy (removal of three and a half glands) 1
  • Total parathyroidectomy with parathyroid tissue autotransplantation (TPTX+AT) 1
  • Total parathyroidectomy (TPTX) 1
• Recent evidence suggests TPTX may have advantages over TPTX+AT in reducing relapse of secondary hyperparathyroidism 1
• Parathyroidectomy should be considered for tertiary hyperparathyroidism (persistent hypercalcemic hyperparathyroidism) despite optimized active vitamin D and cinacalcet therapy 1

Postoperative Management

• Monitor ionized calcium every 4-6 hours for the first 48-72 hours after surgery, then twice daily until stable 1
• If ionized calcium falls below normal (<0.9 mmol/L):
  • Initiate calcium gluconate infusion at 1-2 mg elemental calcium per kg body weight per hour 1
  • When oral intake is possible, administer calcium carbonate 1-2g three times daily and calcitriol up to 2μg/day 1
  • Adjust phosphate binders as needed based on serum phosphorus levels 1

Imaging for Reoperative Cases

• Imaging with 99Tc-Sestamibi scan, ultrasound, CT scan, or MRI should be performed prior to reoperative parathyroid surgery 1
• Preoperative imaging is essential in the reoperative setting to localize target parathyroid lesions and identify postoperative changes 1

Pitfalls and Caveats

• Parathyroidectomy should not be performed in the absence of documented hyperparathyroidism, even in patients with calciphylaxis 1
• Hypocalcemia is a common postoperative complication that requires vigilant monitoring and prompt treatment 1
• Total parathyroidectomy without autotransplantation may not be ideal for patients who may subsequently receive a kidney transplant 1
• Multigland disease affects approximately 15-20% of patients with primary hyperparathyroidism and should be routinely considered 1, 2