What is the treatment for primary hyperparathyroidism?

Treatment of Primary Hyperparathyroidism

Surgical excision of abnormal parathyroid tissue is the only definitive cure for primary hyperparathyroidism and should be recommended for all patients with symptomatic disease and most asymptomatic patients. 1, 2

Surgical Management Options

• Two effective surgical approaches are available for primary hyperparathyroidism:

  • Minimally invasive parathyroidectomy (MIP) - a unilateral operation utilizing limited dissection for targeted removal of only the affected gland 1, 3
  • Bilateral neck exploration (BNE) - a bilateral operation in which all parathyroid glands are identified and examined 1, 3

• MIP offers several advantages over BNE, including shorter operating times, faster recovery, and decreased perioperative costs 3, 2

• MIP requires confident preoperative localization of a single parathyroid adenoma and intraoperative PTH monitoring 3

• BNE remains necessary for cases with discordant or nonlocalizing preoperative imaging or when there is high suspicion for multigland disease 1, 3

Indications for Surgery

• Surgery is indicated for all symptomatic patients with primary hyperparathyroidism 2, 4

• Surgery should be considered for most asymptomatic patients as it is more cost-effective than observation or pharmacologic therapy 4

• Specific indications for surgery in asymptomatic patients include:

  • Age less than 50 years
  • Serum calcium >1 mg/dL above upper limit of normal
  • Bone mineral density T-score ≤-2.5 at any site
  • Vertebral fracture on imaging
  • Creatinine clearance <60 mL/min
  • 24-hour urine calcium >400 mg/day
  • Nephrolithiasis or nephrocalcinosis 4

Preoperative Evaluation

• Measure 25-OH Vitamin D levels to exclude hypovitaminosis D as a concomitant secondary cause of hyperparathyroidism 2

• Preoperative imaging with ultrasound and/or dual-phase 99mTc-sestamibi scintigraphy with SPECT/CT is highly sensitive for localizing parathyroid adenomas 2

• Patients with nonlocalizing imaging remain surgical candidates 4

• Preoperative parathyroid biopsy should be avoided 4

Medical Management

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

Calcium and Vitamin D Management

• Calcium intake should follow guidelines established for all individuals; it is not recommended to limit calcium intake 5

• Patients with low serum 25-hydroxyvitamin D should be repleted with doses aiming to bring levels to ≥50 nmol/L (20 ng/mL) at minimum, though a goal of ≥75 nmol/L (30 ng/mL) is reasonable 5

Pharmacological Approaches

• Cinacalcet is indicated for the treatment of hypercalcemia in adult patients with primary hyperparathyroidism for whom parathyroidectomy would be indicated on the basis of serum calcium levels, but who are unable to undergo parathyroidectomy 6

• Cinacalcet reduces serum calcium concentrations to normal in many cases but has only a modest effect on serum PTH levels and does not improve bone mineral density 5

• Bisphosphonate therapy (particularly alendronate) can be used to improve bone mineral density at the lumbar spine without altering serum calcium concentration 5

• For patients needing both calcium reduction and improved bone mineral density, combination therapy with cinacalcet and bisphosphonates may be reasonable 5

Postoperative Management

• Monitor ionized calcium every 4-6 hours for the first 48-72 hours after surgery, then twice daily until stable 3, 2

• Calcium supplementation may be indicated postoperatively 2

• Follow-up to assess for cure defined as eucalcemia at more than 6 months 4

Special Considerations

• Familial primary hyperparathyroidism, reoperative parathyroidectomy, and parathyroid carcinoma are challenging entities that require special expertise 4

• High-volume parathyroid surgeons have better outcomes 4

• The possibility of multigland disease should be routinely considered 4