From the Guidelines
Surgical removal of the abnormal parathyroid gland(s) through parathyroidectomy is the definitive treatment for primary hyperparathyroidism (PHPT), and is typically indicated even in asymptomatic patients due to the potential negative effects of long-term hypercalcemia. The management of PHPT involves a thorough evaluation of the patient's condition, including biochemical testing and imaging studies to localize the abnormal gland(s) [ 1 ].
Indications for Surgery
The decision to operate is based on several factors, including the presence of symptoms, age, serum calcium levels, kidney function, and bone density [ 1 ]. Patients with symptoms such as kidney stones, osteoporosis, fractures, or neuromuscular symptoms are typically recommended for surgery. Additionally, patients younger than 50 years, with serum calcium levels >1 mg/dL above normal, reduced kidney function (GFR <60 mL/min), or bone density T-score below -2.5 are also considered for surgical intervention [ 1 ].
Preoperative Localization and Surgical Approach
Preoperative localization with imaging studies such as sestamibi scan and/or ultrasound helps identify the abnormal gland(s) and guides the surgical approach [ 1 ]. Minimally invasive parathyroidectomy (MIP) is often possible when a single adenoma is identified, and is associated with shorter operating times, faster recovery, and decreased perioperative costs [ 1 ]. However, bilateral neck exploration (BNE) may be necessary in cases of discordant or nonlocalizing preoperative imaging, or when there is high suspicion for multigland disease [ 1 ].
Medical Management
For asymptomatic patients who do not meet surgical criteria, medical management includes monitoring calcium and PTH levels every 6-12 months, maintaining adequate hydration, avoiding thiazide diuretics, and ensuring normal vitamin D levels [ 1 ]. Medications such as cinacalcet may be used to lower calcium levels, and bisphosphonates may be used for patients with osteoporosis [ 1 ]. Patients should maintain adequate hydration and moderate calcium intake, rather than severe restriction, and regular monitoring of bone density and kidney function is essential for those managed non-surgically [ 1 ].
Outcome
Surgery offers the best chance for cure, with success rates exceeding 95% when performed by experienced surgeons [ 1 ]. The goal of treatment is to alleviate symptoms, prevent long-term complications, and improve quality of life, with a focus on minimizing morbidity and mortality.
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 management of primary hyperparathyroidism (PHPT) with cinacalcet includes:
- 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.
- 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. Key points:
- Cinacalcet is used to treat hypercalcemia in patients with primary HPT who cannot undergo parathyroidectomy.
- Dose titration is necessary to achieve normalized serum calcium levels.
- Monitoring of serum calcium levels is crucial to avoid hypocalcemia 2.
From the Research
Management of Primary Hyperparathyroidism (PHPT)
The management of PHPT involves several key aspects, including:
- Surgical management, which is the only definitive treatment for PHPT 3, 4, 5
- Medical management, which may be used for patients with mild disease, but has been shown to be less effective than parathyroidectomy in some studies 6, 7
- Evaluation and management of asymptomatic patients, which is a topic of ongoing debate 4, 7
Surgical Management
Surgical management of PHPT has evolved over the past several decades, with advances in imaging modalities, operative approaches, and intraoperative adjuncts 3, 5. The goal of surgery is to remove the abnormal parathyroid gland(s) while preserving normal parathyroid function. Techniques used in surgical management include:
- Bilateral neck exploration, which is the gold standard of treatment for PHPT 5
- Unilateral neck explorations, which may be used in patients with localized disease 5
- Minimally invasive parathyroidectomies, which offer improved cosmetic results and reduced risk of complications 5
- Minimally invasive radio-guided parathyroidectomy, which uses radioactive tracers to localize abnormal parathyroid tissue 5
Medical Management
Medical management of PHPT may be used for patients with mild disease or those who are not candidates for surgery 6, 7. Medical treatment options include:
- Calcium-lowering medications, such as bisphosphonates 7
- Cinacalcet, which reduces parathyroid hormone levels 7
- Vitamin D supplementation, which may be used to manage vitamin D deficiency 4
Evaluation and Management of Asymptomatic Patients
The evaluation and management of asymptomatic patients with PHPT is a topic of ongoing debate 4, 7. Guidelines recommend that asymptomatic patients be evaluated for surgery if they meet certain criteria, such as: