HYPERPARATHYROIDISM TREATMENT

From: www.uptodate.com

Non-surgical treatment — Non-surgical treatment may be recommended for people who have no symptoms and whose blood calcium is only mildly elevated. Blood calcium levels should be measured every six months, and tests of kidney function are recommended once per year. Bone density testing is usually recommended every one to three years, depending upon your situation. (See "Management of primary hyperparathyroidism").

General measures — Patients with hyperparathyroidism who do not have symptoms are advised to:

Avoid lithium (a mood stabilizer used for bipolar illness) and thiazide diuretics (used to treat high blood pressure) since these drugs may further increase blood calcium levels.
Avoid excessive loss of body fluids (eg, dehydration), prolonged bed rest or inactivity, and a high calcium diet since these can increase blood calcium levels.
Minimize bone loss by remaining active.
Drink an adequate amount of fluid throughout the day. This may help to minimize the risk of kidney stones.
Maintain a moderate calcium intake (about 1000 mg/day, show table 1 and show table 2). Lower calcium intake will stimulate more PTH secretion while higher calcium intake may worsen high calcium levels. (See "Patient information: Calcium and Vitamin D for bone health").
Consume a moderate amount of vitamin D (400 to 600 IU daily, show table 3). Vitamin D deficiency can stimulate PTH secretion and bone resorption and should be avoided. (See "Patient information: Vitamin D deficiency")
Treat bone loss — Medications that inhibit bone resorption may be prescribed if you have evidence of decreased bone density (osteopenia or osteoporosis). These medications can protect the bones from the bone thinning effects of excess parathyroid hormone but will not normalize the calcium levels in the blood.

A full discussion of treatments for osteoporosis is available separately. (See "Patient information: Osteoporosis prevention and treatment").

Trials are currently ongoing to evaluate the safety and efficacy of drugs that decrease parathyroid hormone levels; this could reverse all the effects of hyperparathyroidism, including elevations in serum calcium levels.

Surgical treatment — Surgery is often recommended for people whose blood calcium is moderately elevated. Surgery is also recommended for people who are excreting a significant amount of calcium through their urine and for people with signs of impaired kidney function or decreased bone density. (See "Preoperative localization and surgical therapy of primary hyperparathyroidism").

It is also recommended if the person is less than 50 years old or if periodic follow-up would be difficult (eg, if a person lived a great distance from a healthcare provider or travels to places where it is difficult to find medical care).

Traditional surgery — The surgery is usually performed while the person is under anesthesia. An incision is made in the lower neck measuring 5 to 10 cm (2 to 5 inches). All four parathyroid glands are examined; usually, at least one abnormal-appearing gland is removed while the normal-appearing glands are left in place.

Minimally invasive surgery — Minimally invasive surgery can be performed in cases where one abnormal parathyroid gland has been located by a pre-operative imaging study.

The surgery can be performed under local nerve block, and is an alternative when one abnormal gland has been localized pre-operatively. This procedure is also a good alternative for patients who are at high-risk for general anesthesia. During the surgery, a small incision (2 to 4 cm or 0.8 to 1.8 inches) is made in the neck and the abnormal tissue is removed. The patient's blood level of PTH is tested before and immediately after removal to confirm that the PTH level drops significantly after the abnormal tissue is removed.

The advantage of minimally invasive surgery compared to traditional surgery is that it requires a smaller incision, less time under anesthesia, and a shorter hospital stay. This procedure is only available for people with certain characteristics and it requires an experienced surgeon and medical center. (See "Preoperative localization and surgical therapy of primary hyperparathyroidism").

Effectiveness of surgery — With an experienced endocrine surgeon, surgical treatment is effective in curing hyperparathyroidism in about 95 percent of patients. The complication rate associated with surgery is very low.

Complications could include temporary or permanent damage to the other parathyroid glands resulting in low calcium levels and/or temporary or permanent hoarseness. Patients are hospitalized for a short time after surgery, usually for less than two days.

Occasionally, some abnormal parathyroid tissue goes undetected and is not removed during the first operation. In this case, high calcium levels and symptoms of hyperparathyroidism persist after surgery. Imaging studies are required to locate the abnormal parathyroid tissue. In some patients, parathyroid glands may be present in unusual locations, such as in the chest or in other regions of the neck. A second surgical procedure is usually required to remove remaining abnormal tissue.

Follow up care after surgery — Six to eight weeks after surgery, most clinicians recommend a blood test to measure the blood level of calcium and PTH. These tests are then repeated once per year to ensure that they remain normal and that abnormal tissue has not regrown. A bone density test may be recommended one year after surgery to guide treatment of bone loss (osteopenia or osteoporosis) (see "Bone density testing" above).