Question

Management of primary hyperparathyroidism.

Hint:

Parathyroidectomy is the most effective treatment for symptomatic primary hyperparathyroidism. Medical management may be considered in asymptomatic or inoperable cases.

Answer 1

Primary hyperparathyroidism (PHPT) is a condition characterized by an overproduction of parathyroid hormone (PTH), usually caused by a benign parathyroid adenoma, hyperplasia, or, rarely, parathyroid carcinoma. The management of PHPT depends on the severity of the disease, symptoms, and laboratory findings.
Management of Primary Hyperparathyroidism:
1. Surgical Management (Parathyroidectomy):
- Surgery is the definitive treatment for symptomatic PHPT or in cases with high calcium levels (serum calcium & gt;1.0 mg/dL above normal) and reduced bone mineral density.
- Neck exploration: This involves the surgical removal of the parathyroid gland(s) responsible for excess hormone production. In most cases, a single adenoma is removed, but in some instances, multiple glands may need to be removed in the case of hyperplasia.
- Minimally invasive parathyroidectomy: This is performed when the localization of the abnormal parathyroid gland(s) is determined using imaging techniques (e.g., sestamibi scan or ultrasonography).
2. Medical Management:
- Observation: Asymptomatic patients with mild hypercalcemia and no significant evidence of complications (e.g., osteoporosis, kidney stones) may be monitored with regular calcium and PTH levels.
- Bisphosphonates (e.g., zoledronic acid) or denosumab: Used to treat osteoporosis or bone loss in patients with PHPT.
- Cinacalcet: A calcimimetic agent used in patients who are not candidates for surgery, it works by increasing the sensitivity of the parathyroid glands to calcium, thus lowering PTH levels.
3. Management of Hypercalcemia:
- Hydration: IV saline hydration is the first step in treating acute hypercalcemia.
- Loop diuretics: After proper hydration, furosemide may be used to promote calcium excretion in the urine.
- Calcitonin and bisphosphonates can be used as adjuncts in severe cases to rapidly lower calcium levels.
4. Long-term Follow-up:
- Patients who undergo surgery require regular monitoring of calcium and PTH levels post-operatively.
- Bone mineral density testing is also important to monitor for osteoporosis and the effects of hypercalcemia on bone health.