What is the first‑line treatment for primary hyperparathyroidism in a patient who meets surgical criteria (serum calcium >1 mg/dL above the upper limit of normal, age <50 years, decreased bone density, nephrolithiasis, or impaired renal function)?

Treatment for Primary Hyperparathyroidism Meeting Surgical Criteria

Parathyroidectomy is the first-line and only curative treatment for primary hyperparathyroidism in patients meeting surgical criteria, and should be performed without delay. 1, 2

Surgical Indications Met

Your patient meets multiple established surgical criteria according to the American College of Endocrinology and American College of Radiology 1, 2:

• Serum calcium >1 mg/dL above upper limit of normal 1
• Age <50 years 1, 3
• Decreased bone density (osteoporosis) 1
• Nephrolithiasis 1
• Impaired renal function (GFR <60 mL/min/1.73 m²) 1

Meeting even one of these criteria warrants surgery; this patient meets all five, making the surgical indication unequivocal. 1, 2

Preoperative Workup

Before surgery, complete the following diagnostic steps:

• Confirm diagnosis biochemically by measuring serum calcium (corrected for albumin) and intact PTH simultaneously 1, 2
• Assess vitamin D status to rule out vitamin D deficiency causing secondary hyperparathyroidism 1, 2
• Obtain preoperative localization imaging to determine surgical approach 2

Imaging Strategy

99Tc-sestamibi scan has the highest sensitivity for localizing parathyroid adenomas and should be the first-line imaging modality. 1, 2 Additional options include ultrasound, 4-D parathyroid CT, or MRI based on institutional expertise. 2

Critical caveat: Imaging is used only for surgical planning, not to confirm or exclude the diagnosis—diagnosis is biochemical only. 2

Surgical Approach Selection

Minimally Invasive Parathyroidectomy (MIP)

MIP is the preferred approach when preoperative imaging confidently localizes a single parathyroid adenoma (which accounts for 80-85% of primary hyperparathyroidism cases). 1, 2

MIP advantages include:

• Shorter operating times 1, 2
• Faster recovery 1, 2
• Decreased perioperative costs 1, 2
• Requires intraoperative PTH monitoring 1

Bilateral Neck Exploration (BNE)

BNE is necessary when preoperative imaging is discordant, nonlocalizing, or multigland disease is suspected. 2

Medical Management: Only for Non-Surgical Candidates

Medical therapy should be reserved exclusively for patients who cannot or refuse surgery, as it is not curative. 3, 4

For Hypercalcemia Control

Cinacalcet is the treatment of choice to lower serum calcium (normalizes calcium in many cases) but has only modest effects on PTH and does not improve bone density. 4

For Bone Protection

Alendronate (bisphosphonate) is recommended to improve lumbar spine BMD without altering serum calcium. 4 However, the effect on fracture risk reduction remains unknown. 3

Calcium and Vitamin D Management

• Do not restrict calcium intake—follow standard dietary guidelines for the general population 4
• Replete vitamin D deficiency to achieve 25-hydroxyvitamin D levels ≥50 nmol/L (20 ng/mL) at minimum, with a goal of ≥75 nmol/L (30 ng/mL) being reasonable 4

Critical Pitfalls to Avoid

• Do not use imaging to diagnose primary hyperparathyroidism—diagnosis is biochemical only 2
• Be aware that PTH assays vary significantly between laboratories—use assay-specific reference values 1, 2
• Do not delay surgery in patients meeting criteria—long-term hypercalcemia has negative effects on multiple organ systems 2
• Ensure adequate vitamin D repletion before surgery to avoid postoperative hungry bone syndrome 1

Expected Surgical Outcomes

In the hands of an experienced surgeon:

• Success rate: 95-98% 5
• Permanent complication rate: 1-3% 5