Endocrine Abstracts (2009) 20 S13.2

Management of mild primary hyperparathyroidism

Jens Bollerslev

Section of Endocrinology, Department of Medicine, Oslo University Hospital, Oslo, Norway.

The clinical presentation of primary hyperparathyroidism has changed dramatically after increased accessibility to biochemical auto-analysers and the diagnosis is today often made by change in patients without specific symptoms. Operative treatment is recommended in patient with markedly increased calcium levels or typical symptoms. However, the vast majority of patients in the modern clinic do not present organ related symptoms and their calcium levels are only slightly increased, or even within the upper limit of normal. Several consensus development conferences have discussed management of these patients with mild, borderline pHPT during the last twenty years.

It has been a matter of debate whether neuro-psychiatric symptoms is a clinical manifestation in mild pHPT and to what extent Quality of Life (QoL) and cognitive function would improve following operative treatment. Systematic randomized studies on these patients with up to two years observation time have so far not indicated benefit of surgery. It has to be taken into account that the studies were based on generic not disease specific questionnaires. At present, it is not recommended to regard impaired QoL and psychiatric symptoms as indications for operation. Another central question is the cardiovascular (CV) aspects of pHPT. Case control studies have indicated increased CV-risk and benefit of operation. Mild pHPT has also been related to central obesity and insulin resistance. However, recent data do not indicate benefit of operation on CV-profile including markers of insulin resistance, despite normalisation of PTH and bone turn-over markers following surgery.

Long term prospective studies in mild pHPT have indicated significant bone loss in the ten to fifteen year perspective, however based on very few observations. On the other hand, there is growing evidence from recent prospective studies based on consensus guidelines that patients safely can be followed conservatively for some years. In years to come these studies may reveal whether this also holds for the longer perspective. However, at present no prospective studies are powered to give final answers on hard endpoints such as cardiovascular events and fractures.

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