reference interval for total calcium and >0.12 mmol/L for ion calcium
Surgical Management
Patients with symptomatic PHPT as well as asymptomatic patients who meet any one of the guideline criteria should be advised to undergo parathyroidectomy [4, 24]. Table 3 shows the indication of surgery in PHPT. Surgical consultation can be offered to those who do not meet guidelines for surgery.
Genetic testing is advised for patients suspected of having a genetic disorder, such as young patients (<30 years of age), patients with syndromic findings and/or a positive family history of syndromic PHPT, and patients with multiglandular disease, such as parathyroid carcinoma [4]. The surgical approach for patients with a genetic etiology may differ from those with a sporadic parathyroid adenoma, in that multiglandular disease is more common when there is a genetic etiology. Preoperative localization studies are recommended with ultrasound, 99mTc-sestamibi nuclear scintigraphy, CT, MRI, or PET scans. The choice of preoperative imaging depends on the experience of the surgical center.
Medical Therapies
Adequate hydration and avoidance of dehydration is always recommended. Calcium intake should not be restricted and should follow national guidelines. 25-hydroxyvitamin D levels >20 ng/mL are recommended, although some experts continue to recommend levels of >30 ng/mL. Concerning supplied vitamin D when needed, initial doses of 600–1,000 IU daily are recommended, and serum calcium levels should be monitored during vitamin D supplementation [4].
Cinacalcet, a calcimimetic, is approved for specific indications in PHPT by the European Medicines Agency (EMA) and the US Food and Drug Administration (FDA). The EMA approved the use of cinacalcet for patients with hypercalcemia who meet surgical criteria but in whom parathyroidectomy is not possible or not clinically “appropriate.” The FDA approval is for severe hypercalcemia in patients with PHPT who are unable to undergo parathyroidectomy. Adverse effects of cinacalcet include nausea, vomiting, diarrhea, and headache, but are uncommon when the single 30-mg daily dose is used [4].
Alendronate, a bisphosphonate, improved BMD in patients with PHP. In patients who require both a reduction in serum calcium levels and an improvement in BMD, combination therapy with cinacalcet and alendronate is reasonable, but has only been studied in a retrospective manner [4].
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