What is the primary treatment for primary hyperparathyroidism?

Primary Hyperparathyroidism Treatment

Parathyroidectomy is the only curative treatment for primary hyperparathyroidism and should be performed in patients with hypercalcemia and elevated PTH. 1

Surgical Management: The Definitive Approach

Indications for Surgery

• Surgery is indicated for symptomatic primary hyperparathyroidism and is typically recommended even in asymptomatic patients, given the potential negative effects of long-term hypercalcemia on morbidity and quality of life. 2
• Parathyroidectomy provides documented resolution of bone pain, pruritus, improvement in bone density, and reversal of neurocognitive symptoms. 2

Surgical Approach Selection

Minimally invasive parathyroidectomy (MIP) is the preferred surgical approach when preoperative imaging confidently localizes a single parathyroid adenoma, which accounts for 80-85% of cases. 1

• MIP offers shorter operating times, faster recovery, and decreased perioperative costs compared to bilateral neck exploration (BNE). 3, 1
• MIP requires confident preoperative localization of a single adenoma and intraoperative PTH monitoring to confirm successful removal. 3

Bilateral neck exploration (BNE) remains necessary when:

• Preoperative imaging is discordant or nonlocalizing 3, 1
• Multigland disease is suspected 3, 1
• Familial forms of primary hyperparathyroidism are present 4

Preoperative Imaging Strategy

• Preoperative localization imaging is essential for MIP but not required to establish the surgical indication itself—diagnosis is biochemical only. 1
• Common imaging modalities include 99Tc-sestamibi scan, ultrasound, 4-D parathyroid CT, and MRI, with selection based on surgeon preference, regional expertise, and patient characteristics. 1
• Critical pitfall to avoid: Never use imaging to confirm or exclude the diagnosis of primary hyperparathyroidism; diagnosis requires elevated or high-normal intact PTH in the setting of elevated total or ionized calcium. 2, 1

Reoperative Cases

• For persistent or recurrent hyperparathyroidism, preoperative imaging with 99Tc-Sestamibi, ultrasound, CT, or MRI is mandatory prior to re-exploration. 1
• Reoperations have lower cure rates and higher complication rates than first-time surgery, making precise localization critical. 1

Medical Management: Limited Role

When Medical Management is Considered

Cinacalcet is FDA-approved for 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. 5

• This represents a narrow indication—medical therapy is reserved only for surgical candidates who cannot undergo surgery due to medical contraindications or patient refusal. 5
• The recommended starting dose is 30 mg twice daily, titrated every 2-4 weeks through sequential doses up to 90 mg 3-4 times daily as necessary to normalize serum calcium. 5

Monitoring Requirements for Cinacalcet

• Serum calcium should be measured within 1 week after initiation or dose adjustment. 5
• Once maintenance dose is established, monitor serum calcium every 2 months for patients with primary hyperparathyroidism. 5
• Critical adverse effects: Nausea (63%), vomiting (46%), and hypocalcemia are common, with severe cases potentially leading to dehydration and worsening hypercalcemia. 5

Asymptomatic Patients Without Surgical Indications

• For patients who do not meet surgical criteria, general medical management includes maintaining adequate hydration, avoiding immobilization, and ensuring moderate dietary calcium intake (500-800 mg/day). 6
• Vitamin D deficiency should be corrected, as deficiency can complicate PTH interpretation and cause secondary hyperparathyroidism. 1

Critical Diagnostic Confirmation

• Measure serum calcium and intact PTH simultaneously to confirm diagnosis before any treatment. 1
• Assess vitamin D status, as deficiency is crucial to identify before proceeding with treatment decisions. 1
• Be aware that PTH assays vary significantly between laboratories; use assay-specific reference values. 1

Common Pitfalls to Avoid

• Never delay surgery in surgical candidates to attempt medical management first—surgery is curative and medical therapy is only for those unable to undergo surgery. 1, 5
• Do not use total parathyroidectomy in patients who may subsequently receive kidney transplant, as calcium control becomes problematic. 3, 1
• Avoid using diuretics without caution in patients with primary hyperparathyroidism. 6
• Do not prescribe cinacalcet to patients who are appropriate surgical candidates—this represents off-label use outside FDA indications. 5