The symptoms of the disease, listed above, are indications for surgery. Surgery reduces all cause mortality as well as resolving symptoms. However, cardiovascular mortality is not significantly reduced.The 2002 NIH Workshop on Asymptomatic Primary Hyperparathyroidism developed criteria for surgical intervention . The criteria were revised at the Third International Workshop on the Management of Asymptomatic Primary Hyperparathyroidism . These criteria were chosen on the basis of clinical experience and observational and clinical trial data as to which patients are more likely to have end-organ effects of primary hyperparathyroidism (nephrolithiasis, skeletal involvement), disease progression if surgery is deferred, and the most benefit from surgery. The panel emphasized the need for parathyroidectomy to be performed by surgeons who are highly experienced and skilled in the operation. The Third International Workshop guidelines concluded that surgery is indicated in asymptomatic patients who meet any one of the following conditions:
Serum calcium concentration of 1.0 mg/dL (0.25 mmol/L) or more above the upper limit of normal
Creatinine clearance that is reduced to <60 mL/min
Bone density at the hip, lumbar spine, or distal radius that is more than 2.5 standard deviations below peak bone mass (T score <-2.5) and/or previous fragility fracture
Age less than 50 yearsOperative intervention can be delayed in patients over 50 years of age who are asymptomatic or minimally symptomatic and who have serum calcium concentrations <1.0 mg/dL (0.2 mmol/L) above the upper limit of normal, and in patients who are medically unfit for surgeryMore recently, three randomized controlled trials have studied the role of surgery in patients with asymptomatic hyperparathyroidism.
The largest study reported that surgery resulted in an increase in bone mass, but no improvement in quality of life after one to two years among patients in the following groups:
Untreated, asymptomatic primary hyperparathyroidism
Serum calcium between 2.60 and 2.85 mmol/liter (10.4–11.4 mg/dL)
Age between 50 and 80 yr
No medications interfering with Ca metabolism
No hyperparathyroid bone disease
No previous operation in the neck
Creatinine level < 130 μmol/liter (<1.47 mg/dL)Two other trials reported improvements in bone density and some improvement in quality of life with surgery. Medications
Medications are used when surgery is not indicated or for poor surgical candidates. Calcimimetics are used to reduce the amount of parathyroid hormone released by the parathyroid glands and subsequent hypercalcemia. Other medications used for PHPT includes treatments for osteoporosis such as estrogen replacement therapy, bisphosphonates or denosumab and for treatment hypercalciuria to reduce the risk for kidney stones. Epidemiology
Primary hyperparathyroidism affects approximately 1 per 1,000 people (0.1%), while there are 25–30 new cases per 100,000 people per year in the United States. The prevalence of primary hyperparathyroidism has been estimated to be 3 in 1000 in the general population and as high as 21 in 1000 in postmenopausal women. It is almost exactly three times as common in women as men.Primary hyperparathyroidism is associated with increased all-cause mortality. Children
In contrast with primary hyperparathyroidism in adults, primary hyperparathyroidism in children is considered a rare endocrinopathy. Pediatric primary hyperparathyroidism can be distinguished by its more severe manifestations, in contrast to the less intense manifestations in adult primary hyperparathyroidism.