Nonsurgical management of mild primary hyperparathyroidism – a reasonable option

Primary hyperparathyroidism (PHPT) is a relatively common disorder which is often diagnosed incidentally and characterized in the majority of those affected by mild stable biochemical abnormalities and lack of symptoms. Nephrolithiasis and bone loss leading to an increased risk of fracture are generally accepted complications of PHPT. Some epidemiological studies report associations between PHPT and a wide range of common diseases, but these relationships may be confounded by the increased body weight observed in PHPT. Because there is a dearth of controlled clinical trial evidence in PHPT, optimal management is controversial. For individuals with mild stable PHPT, low fracture risk and no renal stones, observation without intervention is reasonable. Surgical treatment is clearly indicated for patients at risk of severe hypercalcaemia or with nephrolithiasis. For individuals with increased risk of fracture, antiresorptive therapies improve bone mineral density to a similar degree to surgical treatment. Calcimimetic agents may have a role in managing patients with symptomatic PHPT who cannot undergo, or fail, surgical treatment. There is a need for additional randomized clinical trials to inform management of PHPT.