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Invited Commentary
July 15, 2019

Applying the Guidelines for Primary Hyperparathyroidism: The Path Not Taken

Author Affiliations
  • 1Division of Endocrinology and Metabolism, Department of Medicine, University of California, San Francisco
  • 2Division of Endocrinology and Metabolism, University of California, San Francisco
  • 3Endocrine Research Unit, Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California
JAMA Intern Med. 2019;179(9):1227-1229. doi:10.1001/jamainternmed.2019.1738

When the National Institutes of Health convened the first workshop devoted to the diagnosis and management of primary hyperparathyroidism (pHPT) in 1990, astute clinicians had already appreciated that the classic presentation of this disorder, established decades before as symptomatic and progressive, was no longer the typical face of the disease. Primary hyperparathyroidism was being diagnosed with increasing frequency in asymptomatic patients and those for whom reduced bone mass was the main clinical finding. Guidelines published in 1991 from that first National Institutes of Health conference1 outlined the diagnostic criteria and management recommendations for both symptomatic and asymptomatic pHPT and laid down a framework for proposing when surgery should be pursued in asymptomatic disease. Over the next 24 years, these recommendations were updated at least 3 times (in 2002, 2009, and 2014).2-4 At present, the indications for surgical intervention in patients with asymptomatic pHPT include age 50 years or less, serum calcium 1 mg/dL or more above the upper limit of normal, urinary calcium more than 400 mg/24 hours, estimated glomerular filtration rate less than 60 mL/min/1.73 m2, osteoporosis as measured by dual energy x-ray absorptiometry, and nephrolithiasis or nephrocalcinosis as measured by imaging studies.4,5 Admittedly, these indications are based largely on expert opinion rather than data from randomized trials, because few such studies have ever been conducted in patients with pHPT.

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