Primary hyperparathyroidism
Diagnosis
Nonspecific symptoms, fatigue, musculoskeletal pain, constipation, depression, do not correlate with hypercalcemia.[1]
The serum chloride phosphate ratio is high (33 or more) in most patients with primary hyperparathyroidism. [2][3][4] However, thiazide medications have been reported to causes ratios above 33.[5]
Treatment
Medications
For secondary or tertiary hyperparathyroidism, consider:
- phosphate binders such as calcium acetate, calcium carbonate, and sevelamer
- vitamin D analogues such as calcitriol
- calcimimetic therapy such as cinacalcet that inhibit secretion of PTH
Surgery
A consensus statement in 2002 recommended the following indications for surgery[6]:
- Serum calcium (above upper limit of normal): 1.0 mg/dl
- 24-h urinary calcium >400 mg
- Creatinine clearance reduced by 30% compared with age-matched subjects.
- Bone mineral density t-score <-2.5 at any site
- Age <50
More recently, randomized controlled trials have studied the role of surgery in patients with mild or asymptomatic hyperparathyroidism. The largest study reported that surgery showed increase in bone mass, but no improvement in quality of life after one to two years among patients with[7]:
- Untreated, asymptomatic primary hyperparathyroidism
- Serum calcium between 2.60 - 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)
Other trials reported improvements in bone density and some improvement in quality of life with surgery.[8][9][10]
An uncontrolled case series suggests parathyroidectomy may be beneficial in geriatrics.[11]
Prevention
Increased calcium supplementation may help prevent.[12]
References
- ↑ Bargren AE, Repplinger D, Chen H, Sippel RS (2011). "Can biochemical abnormalities predict symptomatology in patients with primary hyperparathyroidism?". J Am Coll Surg 213 (3): 410-4. DOI:10.1016/j.jamcollsurg.2011.06.401. PMID 21723154. Research Blogging.
- ↑ Reeves CD, Palmer F, Bacchus H, Longerbeam JK (1975). "Differential diagnosis of hypercalcemia by the chloride/phosphate ratio". Am. J. Surg. 130 (2): 166-71. PMID 1155729. [e]
This study found a ratio above 33 to have a sensitivity of 94% and a specificity of 96%.
- ↑ Palmer FJ, Nelson JC, Bacchus H (1974). "The chloride-phosphate ratio in hypercalcemia". Ann. Intern. Med. 80 (2): 200-4. PMID 4405880. [e]
- ↑ Broulík PD, Pacovský V (1979). "The chloride phosphate ratio as the screening test for primary hyperparathyroidism". Horm. Metab. Res. 11 (10): 577-9. PMID 521012. [e]
This study found a ratio above 33 to have a sensitivity of 95% and a specificity of 100%.
- ↑ Lawler FH, Janssen HP (1983). "Chloride:phosphate ratio with hypercalcemia secondary to thiazide administration". The Journal of family practice 16 (1): 153-4. PMID 6848626. [e]
- ↑ Bilezikian JP, Potts JT, Fuleihan Gel-H, et al (2002). "Summary statement from a workshop on asymptomatic primary hyperparathyroidism: a perspective for the 21st century". J. Clin. Endocrinol. Metab. 87 (12): 5353-61. PMID 12466320. [e]
- ↑ Bollerslev J, Jansson S, Mollerup CL, et al (2007). "Medical observation, compared with parathyroidectomy, for asymptomatic primary hyperparathyroidism: a prospective, randomized trial". J. Clin. Endocrinol. Metab. 92 (5): 1687-92. DOI:10.1210/jc.2006-1836. PMID 17284629. Research Blogging.
- ↑ Almqvist EG, Becker C, Bondeson AG, Bondeson L, Svensson J (2004). "Early parathyroidectomy increases bone mineral density in patients with mild primary hyperparathyroidism: a prospective and randomized study.". Surgery 136 (6): 1281-8. DOI:10.1016/j.surg.2004.06.059. PMID 15657588. Research Blogging.
- ↑ Ambrogini E, Cetani F, Cianferotti L, et al (2007). "Surgery or surveillance for mild asymptomatic primary hyperparathyroidism: a prospective, randomized clinical trial". J. Clin. Endocrinol. Metab. 92 (8): 3114-21. DOI:10.1210/jc.2007-0219. PMID 17535997. Research Blogging.
- ↑ Rao DS, Phillips ER, Divine GW, Talpos GB (2004). "Randomized controlled clinical trial of surgery versus no surgery in patients with mild asymptomatic primary hyperparathyroidism". J. Clin. Endocrinol. Metab. 89 (11): 5415-22. DOI:10.1210/jc.2004-0028. PMID 15531491. Research Blogging.
- ↑ Stechman MJ, Weisters M, Gleeson FV, Sadler GP, Mihai R (2009). "Parathyroidectomy is safe and improves symptoms in elderly patients with primary hyperparathyroidism (PHPT).". Clin Endocrinol (Oxf) 71 (6): 787-91. DOI:10.1111/j.1365-2265.2009.03540.x. PMID 19222492. Research Blogging.
- ↑ BMJ 2012. http://www.bmj.com/content/345/bmj.e6390