Management of primary hyperparathyroidism in Spain: a national survey
Manuel Muñoz Torres, on behalf of Calcium Study Group
Background: At the Third International Workshop on asymptomatic primary hyperparathyroidism (PHPT), recent data on the disease were reviewed, but limited information of the PHPT management in Europe is available.
Methods: We performed an online questionnaire survey in hospital endocrinology services to determine knowledge of current PHPT recommendations and its management in the clinical practice during 2009 Spain.
Results: Ninety-nine of 131 sites (76%) (giving health coverage to 32.3 million people, 70% of Spanish population) completed the survey. The number of PHPT patients visited in all hospitals during the last year was 7235, from whom 39% were new diagnoses (incidence: 9.95/100 000 person/year), and 61% were follow-up visits of non-parathyroidectomized patients. 80% of cases were asymptomatic. Each centre performed a median (Q1, Q3) of 12 (6, 20) parathyroidectomies per year. The median (Q1, Q3) percentage of curative interventions (at first trial) was 90% (80, 95). The main reasons for not performing surgery were, by decreasing frequency: surgery contraindication, patients refusal, loss of monitoring, limited surgery experience. Most of endocrinologists based diagnosis of PHTP on elevated serum calcium (Ca) and PTH levels (48% required Ca>10.5 mg/dl and elevated PTH). Differential diagnosis with familiar hypocalciuric hypercalcemia was based mainly on urine Ca/creatinine (Cr) ratio (63%). Imaging techniques were applied in 83% of cases. The main criteria for parathyroidectomy in asymptomatic patients were Ca≥11.5 mg/dl (79%), T score < −2.5 SD at any site (91%), age < 50 years (80%) and glomerular filtration rate (GFR) <60 ml/min (82%). Minimally invasive surgery was performed in 42% of centres. Among preferred pharmacological treatments for patients in whom surgery is contraindicated, calcimimetics were the first choice in 69% of cases, followed by bisphosphonates in 28%. Frequency of biochemistry and bone density determinations for non-surgically managed patients were in accordance with international guidelines (100 and 99% of sites ordered Ca and Cr measurements, respectively, at least once a year).
Conclusions: Overall, the Spanish endocrinologists are implementing the recommendations of the guidelines from the Third International Workshop for the management of primary hyperparathyroidism.