What is the treatment for hyperparathyroidism (primary hyperparathyroid syndrome)?

Treatment of Hyperparathyroidism

For primary hyperparathyroidism, surgical removal of abnormal parathyroid tissue through parathyroidectomy is the only definitive cure and should be recommended for all symptomatic patients and most asymptomatic patients. 1, 2, 3

Primary Hyperparathyroidism Treatment

Surgical Management

• Parathyroidectomy is indicated for all patients with symptomatic primary hyperparathyroidism 3, 4
• Surgery should be considered for most asymptomatic patients as it is more cost-effective than observation or pharmacologic therapy 3
• Two effective surgical approaches are available:
  • Minimally invasive parathyroidectomy (MIP) - offers shorter operating times, faster recovery, and decreased costs 1, 2
  • Bilateral neck exploration (BNE) - appropriate for cases with suspected multigland disease 1
• MIP requires confident preoperative localization of a single parathyroid adenoma and intraoperative PTH monitoring 1
• Surgical cure rates are 95-99% in experienced hands 5, 4

Medical Management (when surgery is not possible)

• Cinacalcet is indicated for hypercalcemia in patients with primary hyperparathyroidism who cannot undergo parathyroidectomy 6
• Other medical options include bisphosphonates, hormone replacement therapy, and calcimimetics 7, 8
• Ensure adequate vitamin D levels (target >20 ng/ml) and calcium intake 2, 9

Secondary Hyperparathyroidism Treatment

Initial Medical Management

• Dietary phosphate restriction, phosphate binders, correction of hypocalcemia, and vitamin D sterols 1
• For persistent secondary hyperparathyroidism, calcimimetics (cinacalcet) may be considered 1, 6
• Cinacalcet is specifically indicated for secondary hyperparathyroidism in adult patients with chronic kidney disease on dialysis 6
• Starting dose of cinacalcet is 30 mg once daily, taken with food 6

Surgical Management

• Parathyroidectomy is recommended for severe hyperparathyroidism (persistent serum levels of intact PTH >800 pg/mL) associated with hypercalcemia and/or hyperphosphatemia refractory to medical therapy 10, 1
• Effective surgical options include:
  • Subtotal parathyroidectomy (SPTX) - removal of three and a half glands 10
  • Total parathyroidectomy (TPTX) - removal of all parathyroid tissue 10
  • Total parathyroidectomy with autotransplantation (TPTX+AT) - removal of all glands with reimplantation of tissue fragments 10

Preoperative Evaluation

• Imaging with ultrasound and/or 99mTc-sestamibi scintigraphy with SPECT/CT to localize parathyroid adenomas 2, 9
• Measure 25-OH Vitamin D levels to exclude hypovitaminosis D as a concomitant cause 2, 9
• Patients with nonlocalizing imaging remain surgical candidates 3
• Preoperative parathyroid biopsy should be avoided 3

Post-Surgical Management

• Monitor ionized calcium every 4-6 hours for the first 48-72 hours after surgery, then twice daily until stable 10, 2
• 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 10
• When oral intake is possible, provide calcium carbonate 1-2 g three times daily and calcitriol up to 2 μg/day 10
• Adjust phosphate binders as needed based on serum phosphorus levels 10, 1

Common Pitfalls to Avoid

• Not assessing vitamin D status before treatment can complicate interpretation of PTH levels 9
• Using different PTH assay generations without considering their varying sensitivity can affect clinical decisions 9
• Cinacalcet is not indicated for patients with CKD who are not on dialysis due to increased risk of hypocalcemia 6
• Preoperative parathyroid biopsy should be avoided as it may cause scarring and complicate subsequent surgery 3