What is the best approach to managing hyperparathyroidism?

Management of Hyperparathyroidism

The best approach to managing hyperparathyroidism depends on the type (primary, secondary, or tertiary) with surgical intervention being the definitive treatment for primary hyperparathyroidism, while secondary hyperparathyroidism initially requires medical management targeting underlying causes, with parathyroidectomy reserved for severe cases refractory to medical therapy. 1, 2

Primary Hyperparathyroidism Management

• Surgical excision of abnormal parathyroid tissue is the only definitive cure for primary hyperparathyroidism 2
• Two effective surgical approaches include:
  • Minimally invasive parathyroidectomy (MIP) - offers shorter operating times, faster recovery, and decreased costs 1
  • Bilateral neck exploration (BNE) - remains the gold standard and is necessary for cases with discordant/nonlocalizing imaging or suspected multigland disease 1, 3
• MIP requires confident preoperative localization of a single parathyroid adenoma and intraoperative PTH monitoring 1
• Preoperative imaging with ultrasound and/or dual-phase 99mTc-sestamibi scintigraphy with SPECT/CT helps localize parathyroid adenomas 2

Secondary Hyperparathyroidism Management

Medical Management (First-Line)

• Initial treatment includes:

  • Dietary phosphate restriction 1, 4
  • Phosphate binders (calcium-based or non-calcium based) 4
  • Correction of hypocalcemia 1
  • Vitamin D supplementation targeting 25-OH vitamin D levels >20 ng/ml 2
  • Vitamin D sterols (calcitriol, paricalcitol, doxercalciferol) with dosage adjusted according to severity 1, 4

• For vitamin D therapy:

  • Oral calcitriol starting dose: 0.25 mcg/day, may increase by 0.25 mcg/day at 4-8 week intervals if needed 5
  • Paricalcitol dosing based on iPTH/80 formula with screening serum calcium ≤9.5 mg/dL 6
  • Monitor serum calcium at least twice weekly during dose titration 5

• For persistent elevated PTH despite vitamin D therapy:

  • Consider calcimimetics (cinacalcet) with caution due to potential hypocalcemia 1, 4

Surgical Management (For Refractory Cases)

• Parathyroidectomy should be recommended for:

  • Severe hyperparathyroidism (persistent serum levels of intact PTH >800 pg/mL) 1, 2
  • Hypercalcemia and/or hyperphosphatemia refractory to medical therapy 1, 4
  • Cases where hypercalcemia precludes medical therapy 4

• Effective surgical options include:

  • Subtotal parathyroidectomy 1, 4
  • Total parathyroidectomy with parathyroid tissue autotransplantation 1, 4
  • Total parathyroidectomy 1, 4

• Total parathyroidectomy may be superior to total parathyroidectomy with autotransplantation in terms of lower recurrence rates of secondary hyperparathyroidism 4

Monitoring During Treatment

For Medical Management

• For patients on vitamin D sterols:
  • Monitor serum calcium and phosphorus every 2 weeks for 1 month after initiation or dose increase, then monthly 1
  • Monitor PTH monthly for at least 3 months, then every 3 months once target levels achieved 1

For Surgical Management

• Postoperative monitoring:
  • Check ionized calcium every 4-6 hours for the first 48-72 hours after surgery, then twice daily until stable 1, 4, 2
  • Initiate calcium gluconate infusion if calcium levels fall below normal 2
  • Adjust phosphate binders as needed based on serum phosphorus levels 2

Common Pitfalls and Caveats

• Total parathyroidectomy is not recommended for patients who may subsequently receive a kidney transplant, as control of serum calcium levels may be problematic 7
• Negative imaging is not a contraindication for parathyroid surgery and is not a criterion for the presence or absence of surgical indication 3
• Complication rates are higher in secondary surgery, thus selective surgery should be performed under guidance of an imaging modality in these cases 3
• Hypocalcemia is a common complication after parathyroidectomy and requires careful monitoring and management 4
• Do not delay surgical intervention in patients with recurrent renal stones and hyperparathyroidism, as this can lead to progressive renal damage 2