How is primary hyperparathyroidism treated?

What is Primary hyperparathyroidism?

Medical treatment

There is at present no effective medical treatment to control primary hyperparathyroidism. Conservative management is really little else than a wait and see policy, embarking on surgery when complications occur or bone density deteriorates. If there are no contraindications hormonal replacement is considered advisable in postmenopausal women. When a conservative approach is used the patient must be checked yearly for any deterioration in calcium levels, kidney function and bone density.

Although there is no effective medical treatment for hyperparathyroidism, there are novel developments that involve the parathyroid calcium sensor (calcium receptor). Parathyroid cells detect changes in plasma calcium levels by virtue of a calcium receptor located on the cell surface. Drugs that mimic or potentiate the effects of serum calcium on the calcium receptor are called calcimimetics. A first generation calcimimetic, NPS R-568 has been shown to lower the serum calcium in postmenopausal patients with parathyroid tumours. There is hope yet for a satisfactory medical treatment for hyperparathyroidism!

Surgery

This is the best form of treatment for primary hyperparathyroidism. The essential principle is to remove the parathyroid gland or glands that are producing the excess hormone. There are three possible types of operation.

1. Subtotal parathyroidectomy - the abnormal tissue is removed, leaving normal parathyroid tissue behind.

2. Total parathyroidectomy - this is where all the parathyroid tissue is removed.

3. Total parathyroidectomy and autotransplantation - this is where total parathyroidectomy is accompanied by the implantation of some normal parathyroid tissue dissected from the patient's own glands into the patient's forearm. The implant acts as functioning parathyroid tissue.

The type of operation performed depends on what is found during surgery. Details of this are given in the section 'Surgery - what may be found at operation'.

The traditional reasons for doing surgery are listed below:

1. Hypercalcaemia in all patients below 50 years.
2. Hypercalcaemia greater than 3.00 mmol/l in all age groups.
3. Symptomatic hypercalcaemia in all age groups.
4. Deterioration in renal function.
5. Progressive reduction in bone density.
6. Excessive excretion of calcium in the urine.
7. Any suggestion of malignant parathyroid disease.

Before the operation a number of tests must be performed to localise the tumour and assess the wellbeing of the patient. This, together with details of the procedure, can be found in the section 'Parathyroid surgery'.