Medical Management of Primary Hyperparathyroidism

Medical management could be an option in selected patients with primary hyperparathyroidism with failed surgery, contraindication to surgery, or unwilling to undergo surgery. Calcium intake should not be restricted and vitamin deficiency/insufficiency should be corrected in all patients. Bisphosphonates and estrogen therapy increase bone mineral density (BMD) and decrease bone turnover, but have no significant impact on serum calcium or PTH levels. Cinacalcet reduces serum calcium and, to less extent, PTH, but has no effect on BMD. Bisphosphonates (alendronate) may be appropriate for patients with mild asymptomatic hypercalcemia and low BMD to prevent further bone loss. On the other hand, cinacalcet could be used to control serum calcium in patients with moderate/symptomatic hypercalcemia without overt bone disease. Combined therapy with cinacalcet and alendronate could be considered in patients with symptomatic hypercalcemia and low BMD with increased risk for fracture.