Feb. 07, 2023

Primary hyperparathyroidism has a broad range of presentations. In fact, patients with overt symptoms such as low-impact fractures and nephrolithiasis have clear indications for surgery, while others may present with mild hypercalcemia and no definitive sequelae.

The recent Evaluation and Management of Primary Hyperparathyroidism: Summary Statement and Guidelines from the Fifth International Workshop position statement includes updated recommendations regarding patients who may benefit from surgical management for primary hyperparathyroidism. It also provides guidelines on monitoring and follow-up for patients who are not candidates for surgery or those who choose to pursue medical therapy.

"These guidelines reflect a consolidation of the latest research regarding primary hyperparathyroidism," says Bart L. Clarke, M.D., one of the authors of the guidelines and an endocrinologist at Mayo Clinic in Rochester, Minnesota.

Several surgical criteria remain the same as the past iteration of the guidelines. For example, osteoporosis, occult vertebral fractures, age less than 50, GFR<60 ml/min, nephrocalcinosis/nephrolithiasis, and calcium >1mg/dL above reference range all persist as indications with strong recommendations for surgical treatment.

New to the 2022 guidelines is acceptance of a lower cutoff for 24-hour urinary calcium excretion — 300 mg/24 hours for men and 250 mg/24 hours for women — acknowledging the effects of hypercalciuria as a surrogate for potential nephrolithiasis as well as bone health. This is in contrast to the Third Consensus Conference, which eliminated urinary calcium excretion as a criteria for surgery for patients with primary hyperparathyroidism.

"This is a great framework for discussing the potential benefits of parathyroid surgery," says Melanie L. Lyden, M.D., chair of the Division of Endocrine and Metabolic Surgery at Mayo Clinic's campus in Rochester, Minnesota. "Even within our group, there are nuances to how we approach patients with this complex disease, but these updated guidelines allow the discussion to focus on evidence-based information while taking into account the uniqueness of each patient."

Other important additions to the new guidelines include:

• A subsection on the diagnosis of normocalcemic primary hyperparathyroidism.
• A strong emphasis on choosing an experienced surgeon who performs at least 50 parathyroidectomies a year.

The committee also concluded that the evidence was not sufficient to recommend surgical intervention in patients with primary hyperparathyroidism to improve neurocognitive function, quality of life or cardiovascular indices.

Dr. Clarke says, "We are constantly evaluating new data to help guide recommendations for surgical and medical management of patients with primary hyperparathyroidism. These guidelines are a valuable resource for primary care providers, endocrinologists and surgeons as it provides updated objective criteria on how to approach patients with this disease."

Using the guidelines as a framework, each patient with primary hyperparathyroidism should be evaluated as an individual with shared decision-making utilized to decide the best course of treatment.

For more information

Bilezikian, JP, et al. Evaluation and Management of Primary Hyperparathyroidism: Summary Statement and Guidelines from the Fifth International Workshop. The American Society for Bone and Mineral Research. 2022;37:2293.

Refer a patient to Mayo Clinic.