Medical Management of Asymptomatic Primary Hyperparathyroidism: Proceedings of the Third International Workshop

BACKGROUND: Primary hyperparathyroidism (PHPT) is a common endocrine disorder that is frequently asymptomatic. The 2002 International Workshop on Asymptomatic PHPT addressed medical management of asymptomatic PHPT and summarized the data on nonsurgical approaches to this disease. At the Third International Workshop on Asymptomatic PHPT held in May 2008, this subject was reviewed again in light of data that have since become available. We present the results of a literature review of advances in the medical management of PHPT. METHODS: A series of questions was developed by the International Task Force on PHPT. A comprehensive literature search for relevant studies evaluating the management of PHPT with bisphosphonates, hormone replacement therapy, raloxifene, and calcimimetics was conducted. Existing guidelines and recent unpublished data were also reviewed. All selected relevant articles were reviewed, and the questions developed by the International Task Force were addressed by the Consensus Panel. RESULTS: Bisphosphonates and hormone replacement therapy are effective in decreasing bone turnover in patients with PHPT and improving bone mineral density (BMD). Fracture data are not available with either treatment. Raloxifene also lowers bone turnover in patients with PHPT. None of these agents, however, significantly lowers serum calcium or PTH levels. The calcimimetic cinacalcet reduces both serum calcium and PTH levels and raises serum phosphorus. Cinacalcet does not, however, reduce bone turnover or improve BMD. CONCLUSIONS: Bisphosphonates and hormone replacement therapy provide skeletal protection in patients with PHPT. Limited data are available regarding skeletal protection in patients with PHPT treated with raloxifene. Calcimimetics favorably alter serum calcium and PTH in PHPT but do not significantly affect either bone turnover or BMD. Medical management of asymptomatic PHPT is a promising option for those who are not candidates for parathyroidectomy.