Hypercalcaemia and primary hyperparathyroidism

Hypercalcaemia is most commonly caused by primary hyperparathyroidism (PHPT) or malignancy. PHPT is common, affects more women than men, and is usually due to a solitary parathyroid adenoma. Nowadays, the most common presentation is an incidental finding on blood testing. The only curative treatment is parathyroidectomy. In 2009 the Third International Workshop on the management of asymptomatic primary hyperparathyroidism updated their guidance on management of asymptomatic PHPT. They recommend surgery in: all symptomatic patients; asymptomatic patients with hypercalcaemia above the upper limit of the reference range by more than 0.25 mmol/litre, evidence of end-organ damage, including impaired renal function, and reduced bone mineral density; and patients under 50 years old. In other patients, conservative management with regular monitoring is an acceptable management strategy. Defining ‘asymptomatic’ is not always easy and there is growing awareness of the prevalence of reduced quality-of-life scores among patients with ‘asymptomatic’ PHPT, but there is a lack of definitive evidence showing benefit in these domains following parathyroidectomy. Therefore, careful clinical decision-making is required in this group of patients.