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Hypercalcaemia - Management
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How should I manage a person with suspected primary hyperparathyroidism?
- For information on when to suspect primary hyperparathyroidism, see Determining the underlying cause and Interpreting PTH levels.
- If the person has hypercalcaemia that is severe (adjusted serum calcium concentration greater than 3.40 mmol/L) or symptomatic, admit immediately to hospital.
- If the person has asymptomatic, mild or moderate hypercalcaemia (adjusted serum calcium concentration 3.40 mmol/L or less), refer to an endocrinologist.
Basis for recommendation
Admit if the person has hypercalcaemia that is severe or symptomatic
Referral to an endocrinologist if primary hyperparathyroidism or familial hypocalciuric hypercalcaemia (FHH) are suspected
- When primary hyperparathyroidism or FHH are suspected, because of increased parathyroid hormone levels in the context of hypercalcaemia, referral to an endocrinologist is required (for confirmation of the diagnosis, assessment for the need for parathyroidectomy, and referral to a parathyroid surgeon or, if appropriate, conservative management) [Bilezikian et al, 2009; Eastell et al, 2009; Khan et al, 2009; Silverberg et al, 2009; Udelsman et al, 2009]. This requires experience and expertise in the management of people with primary hyperparathyroidism or FHH. For more information, see Secondary care.
How is primary hyperparathyroidism managed in secondary care?
- In secondary care, the endocrinologist may:
- Confirm the diagnosis, by:
- Excluding other causes of hypercalcaemia.
- Measuring the 25-hydroxyvitamin D level, as this affects the interpretation of parathyroid hormone levels.
- Measuring 24-hour urinary calcium. Low levels indicate familial hypocalciuric hypercalcaemia.
- Assess the need for parathyroidectomy and referral to a parathyroid surgeon. Indications for parathyroidectomy include:
- Symptomatic disease.
- People younger than 50 years of age.
- Kidney stones.
- Adjusted serum calcium concentration that is 0.25 mmol/L or more above the upper end of the reference range.
- Estimated glomerular filtration rate less than 60 mL/min (although this threshold depends on other factors, such as age).
- Reduced bone mineral density at the lumbar spine, femoral neck, total hip, or distal radius (T-score –2.5 or less for peri-menopausal or postmenopausal women, and men 50 years of age or older; Z-score –2.5 or less for premenopausal women and men younger than 50 years of age).
- Manage people who do not undergo parathyroidectomy. This includes:
- Monitoring.
- Vitamin D supplements, if necessary.
- Advice on a normal dietary intake of calcium.
- If appropriate, treatment with a bisphosphonate. Other options for treatment (if required) include hormone replacement therapy, raloxifene, and the calcimimetic drug cinacalcet.
Basis for recommendation
What monitoring is required for a person with asymptomatic, confirmed primary hyperparathyroidism who has not undergone parathyroidectomy?
- Following specialist endocrine assessment, monitoring of people with asymptomatic primary hyperparathyroidism who have no indications for parathyroidectomy or who decline parathyroidectomy may be done in primary care, if this is agreed locally.
- Monitor:
- Serum calcium and renal function — every 12 months.
- Blood pressure — every 6 months; manage as for essential hypertension. See the CKS topic on Hypertension - not diabetic.
- Bone mineral density (at the lumbar spine, femoral neck, total hip, and distal radius) — every 1–2 years, depending on local guidance.
- For symptoms of hypercalcaemia — opportunistically.
- Refer the person back to the endocrinologist if:
- Symptoms of hypercalcaemia develop.
- Adjusted serum calcium concentration increases to 0.25 mmol/L or more above the upper end of the normal range (for example greater than 2.90 mmol/L).
- Estimated glomerular filtration rate is less than 60 mL/min.
- At any site on bone mineral density measurement, the T-score is –2.5 or less (for peri-menopausal or postmenopausal women, and men 50 years of age or older) or the Z-score is –2.5 or less (for premenopausal women and men younger than 50 years of age).
Basis for recommendation
These recommendations are based mainly on international guidelines on the management of asymptomatic primary hyperparathyroidism [Bilezikian et al, 2009; Eastell et al, 2009; Khan et al, 2009; Silverberg et al, 2009; Udelsman et al, 2009]. In addition:
- The information that, following specialist endocrine assessment, monitoring of people with asymptomatic primary hyperparathyroidism (who have no indications for parathyroidectomy or decline parathyroidectomy) may be done in primary care, if this is agreed locally, is based on what CKS considers to be acceptable practice.
- The recommendation to monitor blood pressure every 6 months is based on expert opinion from a narrative review [Davies et al, 2002]. Hypertension is more common in people with primary hyperparathyroidism compared with the general population [Chan et al, 1997]. The cardiovascular risks are not known [Bilezikian et al, 2009] and hypertension does not improve following parathyroidectomy [Chan et al, 1997].
- In the absence of evidence or published opinion, the recommendation to monitor for symptoms of hypercalcaemia opportunistically is based on what CKS considers to be good clinical practice.
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