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Hyperparathyroidism

NICE guideline [NG132] Hyperparathyroidism (primary): diagnosis, assessment and initial management. Published: May 2019.

Diagnosis Guidelines (Primary Hyperparathyroidism)

Albumin-adjusted serum calcium should be measured (not ionised calcium)
 
Condition Calcium Phosphate PTH ALP
Primary hyperparathyroidism ↑ ↓ ↑ ↑
Secondary hyperparathyroidism (from CKD) ↓ ↑ ↑
Tertiary hyperparathyroidism ↑ ↑ ↑↑
Vitamin D deficiency ↓ ↓ ↑

 

NICE recommends first measuring albumin-adjusted serum calcium if primary hyperparathyroidism is suspected, and only to measure PTH level if calcium is elevated. 

However, usually all calcium, phosphate, PTH and ALP would be ordered together. And in exams, one would definitely be expected to interpret all 4 above-listed parameters.

Post-diagnosis of primary hyperparathyroidism, NICE recommends assessing:
  • Vitamin D level
  • eGFR or serum creatinine
  • DEXA
  • Ultrasound of renal tract

FHH is an important differential of primary hyperparathyroidism that also presents with similar biochemical changes (↑ calcium  ↓ phosphate ↑ PTH)

Main distinguishing factors are:

  • ↓ Urinary calcium excretion (<0.01 Ca: Cr clearance ratio)
    • Urinary calcium excretion is high in primary hyperparathyroidism
  • +ve Family history (FHH is autosomal dominant - due to an inactivating mutation in the calcium-sensing receptor)
  • Usually asymptomatic
  • Biochemical changes are mild

Importantly, FHH is managed very differently from primary hyperparathyroidism:
  • Benign lifelong condition
  • Surgery is not indicated and will provide no benefit 
    • Parathyroidectomy will NOT normalise calcium levels

Management Guidelines (Primary Hyperparathyroidism)

Choice of definitive management:
  • 1st line: surgery
  • 2nd line: medical therapy
 

Surgery should be offered in ANY of the following:
  • Symptomatic hypercalcaemia (e.g. thirst, frequent or excessive urination, constipation)
  • Very high calcium levels (albumin-adjusted serum calcium ≥2.85)
  • Any end-organ disease
    • Renal stone
    • Osteoporosis
    • Fragility fractures

Offer pre-operative ultrasound to guide the surgical approach.

Choices depend on ultrasound findings:
  • Single adenoma identified → choice of focused parathyroidectomy or 4-gland exploration
  • All other patients (including those with discordant imaging findings) → 4-gland exploration

Measure albumin-adjusted serum calcium and PTH before discharge.

Long-term monitoring involves measuring albumin-adjusted serum calcium:
  • If it falls within reference range 3-6 months after surgery = successful surgery

Medical management with cinacalcet (CaSRCalcium sensing receptor agonist) should only be considered if:
  • Surgery is inappropriate (unsuccessful / contraindicated / declined by patients), and
  • Symptomatic hypercalcaemia (≥2.85 mmol/L) / asymptmatic hypercalcaemia (≥3 mmol/L)

 
Bisphosphonates should NOT be offered to manage hypercalcaemia in primary hyperparathyroidism.

It should only be offered to reduce the risk of fracture. Refer to this article.

References

Author: Adams Lau
Reviewer:
Last edited: 16/08/25