Hyperparathyroidism Management

Diagnosis and Biochemical Testing

Primary hyperparathyroidism (PHPT) can be diagnosed through biochemical testing, with criteria including elevated or inappropriately normal parathyroid hormone (PTH) levels in the setting of hypercalcemia and low or low-normal phosphorus levels, as suggested by the American College of Radiology 1
Tertiary hyperparathyroidism (THPT) is characterized by a lack of PTH suppression despite rising calcium levels, typically in patients with long-standing secondary hyperparathyroidism (SHPT) 1
Normocalcemic PHPT is characterized by normal serum calcium levels, persistently elevated PTH, and no obvious cause for secondary hyperparathyroidism 1

The American College of Radiology suggests that the addition of SPECT/CT to planar imaging significantly improves localization, providing both functional and anatomical information, and is superior for detecting ectopic glands 1
MRI has a sensitivity of 63-93%, with higher sensitivity at 3.0T, and has advantages including no radiation exposure, making it valuable in reoperative cases, with 3.0T MRI showing promising results with sensitivity up to 98% 1
Imaging modalities for preoperative localization include:

Surgical excision of the abnormally functioning parathyroid tissue is the definitive treatment for parathyroid adenoma, even in asymptomatic patients, as recommended by the American College of Radiology 1
Minimally Invasive Parathyroidectomy (MIP) is the preferred approach when preoperative imaging confidently localizes a single adenoma, with benefits including shorter operating time, faster recovery, and decreased costs, and cure rates of 95-98% when performed by experienced surgeons 2, 1
Bilateral Neck Exploration (BNE) is indicated when preoperative imaging is discordant or non-localizing, multigland disease is suspected, or previous failed surgery 1, 2
Intraoperative PTH monitoring is required to confirm removal of the hyperfunctioning gland, according to the American College of Radiology 1
For patients who cannot undergo surgery, calcimimetics such as cinacalcet can be used to reduce serum calcium levels, starting at 30 mg twice daily and titrated every 2-4 weeks as needed, and bisphosphonates or denosumab can be used for bone protection in patients with osteoporosis 2

Monitor ionized calcium every 4-6 hours for the first 48-72 hours, then twice daily until stable, with adjustments as needed, according to the American Journal of Kidney Diseases 3
If calcium levels fall below normal, initiate calcium gluconate infusion and adjust to maintain normal ionized calcium levels, as guided by the American Journal of Kidney Diseases 3
Calcium supplementation is initiated if calcium drops below normal, with transition to oral calcium carbonate and calcitriol as needed, and long-term follow-up includes serum calcium and PTH at 6 months to confirm cure, and annual monitoring of calcium levels 2
Persistent hyperparathyroidism is defined as failure to achieve normocalcemia within 6 months of surgery, while recurrent hyperparathyroidism occurs after a normocalcemic interval of 6+ months post-surgery, as defined by the American College of Radiology 1
Long-term follow-up is necessary to monitor for recurrence and adjust treatment as needed 2, 1