Primary hyperparathyroidism: Difference between revisions
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==Diagnosis== | ==Diagnosis== | ||
Nonspecific symptoms, fatigue, musculoskeletal pain, constipation, depression, do not correlate with hypercalcemia.<ref name="pmid21723154">{{cite journal| author=Bargren AE, Repplinger D, Chen H, Sippel RS| title=Can biochemical abnormalities predict symptomatology in patients with primary hyperparathyroidism? | journal=J Am Coll Surg | year= 2011 | volume= 213 | issue= 3 | pages= 410-4 | pmid=21723154 | doi=10.1016/j.jamcollsurg.2011.06.401 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21723154 }} </ref> | |||
The serum chloride phosphate ratio is high (33 or more) in most patients with primary hyperparathyroidism. <ref name="pmid1155729">{{cite journal |author=Reeves CD, Palmer F, Bacchus H, Longerbeam JK |title=Differential diagnosis of hypercalcemia by the chloride/phosphate ratio |journal=Am. J. Surg. |volume=130 |issue=2 |pages=166-71 |year=1975 |pmid=1155729 |doi=}}<br><blockquote>This study found a ratio above 33 to have a [[sensitivity (tests)|sensitivity]] of 94% and a [[specificity (tests)|specificity]] of 96%.</blockquote></ref><ref name="pmid4405880">{{cite journal |author=Palmer FJ, Nelson JC, Bacchus H |title=The chloride-phosphate ratio in hypercalcemia |journal=Ann. Intern. Med. |volume=80 |issue=2 |pages=200-4 |year=1974 |pmid=4405880 |doi=}}</ref><ref name="pmid521012">{{cite journal |author=Broulík PD, Pacovský V |title=The chloride phosphate ratio as the screening test for primary hyperparathyroidism |journal=Horm. Metab. Res. |volume=11 |issue=10 |pages=577-9 |year=1979 |pmid=521012 |doi=}}<br><blockquote>This study found a ratio above 33 to have a [[sensitivity (tests)|sensitivity]] of 95% and a [[specificity (tests)|specificity]] of 100%.</blockquote></ref> However, [[thiazide]] medications have been reported to causes ratios above 33.<ref name="pmid6848626">{{cite journal |author=Lawler FH, Janssen HP |title=Chloride:phosphate ratio with hypercalcemia secondary to thiazide administration |journal=The Journal of family practice |volume=16 |issue=1 |pages=153-4 |year=1983 |pmid=6848626 |doi=}}</ref> | The serum chloride phosphate ratio is high (33 or more) in most patients with primary hyperparathyroidism. <ref name="pmid1155729">{{cite journal |author=Reeves CD, Palmer F, Bacchus H, Longerbeam JK |title=Differential diagnosis of hypercalcemia by the chloride/phosphate ratio |journal=Am. J. Surg. |volume=130 |issue=2 |pages=166-71 |year=1975 |pmid=1155729 |doi=}}<br><blockquote>This study found a ratio above 33 to have a [[sensitivity (tests)|sensitivity]] of 94% and a [[specificity (tests)|specificity]] of 96%.</blockquote></ref><ref name="pmid4405880">{{cite journal |author=Palmer FJ, Nelson JC, Bacchus H |title=The chloride-phosphate ratio in hypercalcemia |journal=Ann. Intern. Med. |volume=80 |issue=2 |pages=200-4 |year=1974 |pmid=4405880 |doi=}}</ref><ref name="pmid521012">{{cite journal |author=Broulík PD, Pacovský V |title=The chloride phosphate ratio as the screening test for primary hyperparathyroidism |journal=Horm. Metab. Res. |volume=11 |issue=10 |pages=577-9 |year=1979 |pmid=521012 |doi=}}<br><blockquote>This study found a ratio above 33 to have a [[sensitivity (tests)|sensitivity]] of 95% and a [[specificity (tests)|specificity]] of 100%.</blockquote></ref> However, [[thiazide]] medications have been reported to causes ratios above 33.<ref name="pmid6848626">{{cite journal |author=Lawler FH, Janssen HP |title=Chloride:phosphate ratio with hypercalcemia secondary to thiazide administration |journal=The Journal of family practice |volume=16 |issue=1 |pages=153-4 |year=1983 |pmid=6848626 |doi=}}</ref> | ||
==Treatment== | ==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=== | ===Surgery=== | ||
A consensus statement in 2002 recommended the following indications for surgery<ref name="pmid12466320">{{cite journal |author=Bilezikian JP, Potts JT, Fuleihan Gel-H, ''et al'' |title=Summary statement from a workshop on asymptomatic primary hyperparathyroidism: a perspective for the 21st century |journal=J. Clin. Endocrinol. Metab. |volume=87 |issue=12 |pages=5353-61 |year=2002 |pmid=12466320 |doi=}}</ref>: | A consensus statement in 2002 recommended the following indications for surgery<ref name="pmid12466320">{{cite journal |author=Bilezikian JP, Potts JT, Fuleihan Gel-H, ''et al'' |title=Summary statement from a workshop on asymptomatic primary hyperparathyroidism: a perspective for the 21st century |journal=J. Clin. Endocrinol. Metab. |volume=87 |issue=12 |pages=5353-61 |year=2002 |pmid=12466320 |doi=|url=http://jcem.endojournals.org/cgi/content/full/87/12/5353}}</ref>: | ||
* Serum calcium (above upper limit of normal): 1.0 mg/dl | * Serum calcium (above upper limit of normal): 1.0 mg/dl | ||
* 24-h urinary calcium >400 mg | * 24-h urinary calcium >400 mg | ||
| Line 14: | Line 21: | ||
* Age <50 | * Age <50 | ||
More recently, | More recently, [[randomized controlled trial]]s 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<ref name="pmid17284629">{{cite journal |author=Bollerslev J, Jansson S, Mollerup CL, ''et al'' |title=Medical observation, compared with parathyroidectomy, for asymptomatic primary hyperparathyroidism: a prospective, randomized trial |journal=J. Clin. Endocrinol. Metab. |volume=92 |issue=5 |pages=1687-92 |year=2007 |pmid=17284629 |doi=10.1210/jc.2006-1836}}</ref>: | ||
* Untreated, asymptomatic primary hyperparathyroidism | * Untreated, asymptomatic primary hyperparathyroidism | ||
* Serum calcium between 2.60 - 2.85 mmol/liter (10.4 - 11.4 mg/dl) | * Serum calcium between 2.60 - 2.85 mmol/liter (10.4 - 11.4 mg/dl) | ||
| Line 23: | Line 30: | ||
* Creatinine level < 130 µmol/liter (<1.47 mg/dl) | * Creatinine level < 130 µmol/liter (<1.47 mg/dl) | ||
Other [[randomized controlled trial | trials]] reported improvements in bone density and some improvement in quality of life with surgery.<ref name="pmid15657588">{{cite journal| author=Almqvist EG, Becker C, Bondeson AG, Bondeson L, Svensson J| title=Early parathyroidectomy increases bone mineral density in patients with mild primary hyperparathyroidism: a prospective and randomized study. | journal=Surgery | year= 2004 | volume= 136 | issue= 6 | pages= 1281-8 | pmid=15657588 | |||
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=15657588 | doi=10.1016/j.surg.2004.06.059 }}</ref><ref name="pmid17535997">{{cite journal |author=Ambrogini E, Cetani F, Cianferotti L, ''et al'' |title=Surgery or surveillance for mild asymptomatic primary hyperparathyroidism: a prospective, randomized clinical trial |journal=J. Clin. Endocrinol. Metab. |volume=92 |issue=8 |pages=3114-21 |year=2007 |pmid=17535997 |doi=10.1210/jc.2007-0219}}</ref><ref name="pmid15531491">{{cite journal |author=Rao DS, Phillips ER, Divine GW, Talpos GB |title=Randomized controlled clinical trial of surgery versus no surgery in patients with mild asymptomatic primary hyperparathyroidism |journal=J. Clin. Endocrinol. Metab. |volume=89 |issue=11 |pages=5415-22 |year=2004 |pmid=15531491 |doi=10.1210/jc.2004-0028}}</ref> | |||
An uncontrolled [[case series]] suggests [[parathyroidectomy]] may be beneficial in [[geriatrics]].<ref name="pmid19222492">{{cite journal| author=Stechman MJ, Weisters M, Gleeson FV, Sadler GP, Mihai R| title=Parathyroidectomy is safe and improves symptoms in elderly patients with primary hyperparathyroidism (PHPT). | journal=Clin Endocrinol (Oxf) | year= 2009 | volume= 71 | issue= 6 | pages= 787-91 | pmid=19222492 | |||
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=19222492 | doi=10.1111/j.1365-2265.2009.03540.x }}</ref> | |||
==Prevention== | |||
Increased calcium supplementation may help prevent.<ref>BMJ 2012. http://www.bmj.com/content/345/bmj.e6390</ref> | |||
==References== | ==References== | ||
<references/> | <references/>[[Category:Suggestion Bot Tag]] | ||
Latest revision as of 06:00, 7 October 2024
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