Primary hyperparathyroidism: diagnosis and management.
OBJECTIVE
To review the manifestations of primary hyperparathyroidism and the available treatment strategies.


METHODS
The epidemiologic and pathologic features of this endocrine disorder are outlined. Guidelines for surgical intervention are discussed, and the effectiveness of various medical treatments is summarized.


RESULTS
Primary hyperparathyroidism, a common disorder, is diagnosed on the basis of hypercalcemia in the presence of increased parathyroid hormone levels as measured by immunoassay. Clinical manifestations are variable with many patients being asymptomatic at the time of diagnosis. Patients with severe disease require definitive surgical treatment. Surgical cure rates are high--approximately 95% in experienced hands. Indications for surgery include a serum calcium of more than 2.9 mmol/L (12 mg/dL), osteoporosis, recurrent renal stones, and parathyroid carcinoma. As well, it is recommend in individuals younger than 50 years of age. Patients with mild disease may have a benign natural history and may not have progression to severe disease. Asymptomatic individuals with mild hypercalcemia and close to normal bone mass and renal function may be managed medically, particularly those who are over the age of 50 years. Medical management includes ensuring adequate hydration and avoiding volume depletion. Estrogen therapy is valuable in postmenopausal women without contraindications to hormone replacement. Calcitonin has been shown to decrease serum calcium levels on a short-term basis. Bisphosphonates are also potential treatment options and require further study. Calcium-mimetic agents also may become valuable in the medical management of primary hyperparathyroidism in the near future.


CONCLUSIONS
As primary hyperparathyroidism is being increasingly detected at an asymptomatic stage, medical therapy is assuming a greater role in the effective management of this common condition.
Khan
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Department of Medicine, Division of Geriatrics, McMaster University, Hamilton, Ontario, Canada.