Outcome

Ms M underwent right lower pole parathyroidectomy approximately 4 months after her initial visit to her PCP. Intact PTH immediately before surgery was 138.8 pg/dL (reference range, 23.6-123.6 pg/dL). Intact PTH repeated intraoperatively after excision of the parathyroid gland was within normal limits at 48.2 pg/dL. Ms M continues to follow up with her PCP for her vitamin D deficiency, osteopenia, and thyroid nodules.


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Discussion

This case demonstrates a stepwise multidisciplinary management approach of a seemingly asymptomatic patient who was diagnosed with primary hyperparathyroidism after the incidental finding of mild hypercalcemia on screening laboratory testing. The decision to refer a patient with primary hyperparathyroidism for surgical intervention is controversial; therefore, it is important for PCPs to make appropriate referrals.

Ms M recalls that she understood that surgery was her only option when her parathyroid hormone level was elevated, before she was diagnosed with osteopenia and vitamin D deficiency. During her consultation with the surgeon, she was informed that it was best to have the surgery as soon as possible instead of waiting. The surgeon wanted to ensure that the parathyroid adenoma was not malignant, and he informed her that watchful waiting could result in worsening hypercalcemia and increasing size of the parathyroid adenoma.

Women should be informed that parathyroidectomy is usually indicated in patients who are symptomatic1 and those who meet the criteria for surgery.2 Although the necessity of surgery in the management of patients with primary hyperparathyroidism who are asymptomatic is controversial, the Fourth International Workshop on the Management of Asymptomatic Primary Hyperparathyroidism provides evidence-based criteria for surgery.2

Surgical vs Medical Management

Parathyroidectomy is recommended for patients who have severe renal or bone signs and symptoms of hyperparathyroidism,4 those with symptomatic primary hyperparathyroidism, and asymptomatic patients who are at risk for disease progression.3 With the exception of patients with presentation at age <50 years, it is difficult to predict those patients who will experience disease progression.3   Surgery cures the disease by removing the source of the hyperactivity, reduces the risk of kidney stones, and improves bone mineral density.3 The mortality rate after parathyroidectomy is 0%, and the worrisome complication of injury to the recurrent laryngeal nerve is <1%.4

Patients who would rather not undergo surgery should be monitored. Their serum calcium and creatinine levels should be checked annually to assess for worsening hypercalcemia and renal impairment. Bone density of the hip, spine, and forearm should be requested every 1 to 2 years to evaluate potential bone loss.3

There are some patients who may be symptomatic and/or have severe hypercalcemia, but they may have comorbid contraindications to surgery or make the personal decision not to have surgery. Patients without bone loss should receive cinacalcet 30 mg twice per day, while those with bone loss or osteoporosis should receive a bisphosphonate, preferably alendronate.3 Calcimimetics such as cinacalcet inhibit parathyroid hormone secretion by activating calcium-sensing receptors in the parathyroid gland.3 Serum calcium level should be measured 1 week after initiation of therapy and any dose adjustment(s).3 Dose adjustments may occur every 2 weeks to every month and may be increased from 30 mg twice per day to 60 mg twice per day followed by 90 mg twice per day.5 If calcium levels are not within normal range, the patient can receive cinacalcet 90 mg 3 or 4 times per day.5 Combination bisphosphonate and cinacalcet is indicated in patients with chronic hypercalcemia and osteoporosis. Vitamin D supplementation should be administered to patients with reduced vitamin D levels.3 High-dose vitamin D was prescribed for this patient; however, the recommendation is for patients to take 600 IU/d to 1000 IU/d to prevent exacerbation of hypercalciuria and hypercalcemia.3

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Conclusion

It is important for PCPs to conduct appropriate follow-up of abnormal testing results in order to prevent adverse outcomes in their patients. In this case, the quick action of the initial practitioner with whom Ms M came in contact with resulted in the early identification and treatment of primary hyperparathyroidism and the complication of vitamin D deficiency and osteopenia. As demonstrated in this case, an incidental finding of mildly elevated calcium is not always benign.

Denise M. Linton, DNS, FNP-BC, is associated professor, nurse practice coordinator, and holds the Dudley Joseph Plaisance, Sr./BORSF Professorship in Nursing at the University of Louisiana at Lafayette College of Nursing and Allied Health Professions.

References

  1. Turner JJO. Hypercalcemia – presentation and management. Clin Med. 2017;17(3):270-273.
  2. Bilezikian JP, Bandeira L, Khan A, Cusano NE. Hyperparathyroidism. Lancet. 2018;391(10116):168-178.
  3. Silverberg SJ, Fuleihan GE. Primary hyperparathyroidism: management. UpToDate website. Available at: https://www.uptodate.com/contents/primary-hyperparathyroidism-management?search=primary-hyperparathyroidism-management.&source=search_result&selectedTitle=1~108&usage_type=default&display_rank=1. Updated September 6, 2017. Accessed December 13, 2018.
  4. Udelsman R, Akerstrom G, Biagini C, et al. The surgical management of asymptomatic primary hyperparathyroidism: proceedings of the Fourth International Workshop. J Clin Endocrinolol Metab. 2014;99(10):3595-3606.
  5. Sensipar® (cinacalcet hydrochloride) [product monograph]. Mississauga, Ontario, Canada: Amgen Canada, Inc.; 2018.