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 (PHPT) and is the recommended treatment approach. 1

Surgical Options

• Two effective surgical approaches exist for PHPT:

  • Minimally invasive parathyroidectomy (MIP) - a unilateral operation with limited dissection for targeted removal of only the affected gland 2, 3
  • Bilateral neck exploration (BNE) - a bilateral operation where all parathyroid glands are identified and examined 2, 3

• MIP offers significant advantages over BNE, including:

  • Shorter operating times
  • Faster recovery
  • Decreased perioperative costs 3

• MIP requires:

  • Confident preoperative localization of a single parathyroid adenoma
  • Intraoperative PTH monitoring 3

• BNE remains necessary in cases with:

  • Discordant or nonlocalizing preoperative imaging
  • High suspicion for multigland disease 2, 3

Patient Selection for Surgery

• Surgery is indicated for patients with:

  • Symptomatic hyperparathyroidism (bone disease, kidney stones)
  • Asymptomatic hyperparathyroidism (due to potential negative effects of long-term hypercalcemia) 2
  • Recurrent renal stones with hyperparathyroidism 1

• Preoperative imaging with ultrasound and/or dual-phase 99mTc-sestamibi scintigraphy with SPECT/CT is highly recommended to localize parathyroid adenomas 1, 4

• Negative imaging is not a contraindication for parathyroid surgery 5

Medical Management

• For patients unable to undergo surgery, cinacalcet is FDA-approved for treatment of hypercalcemia in primary HPT 6

• Cinacalcet dosing:

  • Starting dose: 30 mg twice daily
  • Titrate every 2-4 weeks through sequential doses of 30 mg twice daily, 60 mg twice daily, 90 mg twice daily, and 90 mg 3-4 times daily as necessary 6
  • Monitor serum calcium within 1 week after initiation or dose adjustment 6

• Common adverse effects of cinacalcet include:

  • Nausea (30%)
  • Muscle spasms (18%)
  • Headache (12%)
  • Back pain (12%) 6

Surgical Success and Complications

• Parathyroidectomy has a high success rate of 95-98% when performed by an experienced surgeon 7, 8

• Failure rates are low, with studies showing only 1.9% of cases requiring reoperation 8

• Ectopic parathyroid glands (particularly in the mediastinum) are associated with increased risk of surgical failure 8

• Complications are higher in secondary surgeries, making accurate initial localization and successful first surgery crucial 5

Post-Surgical Management

• Monitor ionized calcium every 4-6 hours for the first 48-72 hours after surgery, then twice daily until stable 1

• Provide calcium supplementation if calcium levels fall below normal 1

Special Considerations

• For patients with primary hyperparathyroidism who cannot undergo surgery, cinacalcet is the preferred medical therapy 6

• Ensure adequate vitamin D levels (>20 ng/ml) to exclude hypovitaminosis D as a concomitant secondary cause of hyperparathyroidism 1

• For patients with recurrent renal stones, increase fluid intake to achieve urine volume of at least 2.5 liters daily 1