Primary hyperparathyroidism: an update

Primary hyperparathyroidism (PHPT) is a constantly evolving disease. As more evidence on the cardiovascular and neuropsychiatric manifestations of apparently asymptomatic disease accumulates, and since medical therapeutic options and surgical indications are being further investigated, it is important to review this disease entity to gain a fresh, updated perspective on the current disease phenotype and treatment approach.

The pathogenesis of PHPT has not been completely elucidated yet, but some potential culprits, such as gene mutations, growth factors, calcium sensing receptor antibodies, and chronic vitamin D deficiency are being identified. There is increasing evidence that even mild, asymptomatic PHPT is associated with some aspects of cardiovascular and neuropsychiatric dysfunction, but the clinical significance as well as the reversibility with parathyroidectomy of these abnormalities remain to be determined. Medical therapies such as bisphosphonates and calcimimetics are showing some promise in the treatment of PHPT, although surgery remains the only curative intervention. The indications for surgical intervention in patients with asymptomatic PHPT have been recently revised.

Parathyroidectomy is the treatment of choice for patients with symptomatic PHPT and patients with asymptomatic PHPT who fulfill certain age, bone density, serum calcium, and creatinine criteria. Further research is needed to determine whether patients with prominent cardiovascular and neuropsychiatric manifestations would benefit from such intervention.