[The medical treatment of primary hyperparathyroidism]

The first-choice treatment of primary hyperparathyroidism is surgical removal of abnormal parathyroid gland(s) and the medical management is usually reserved only to control severe hypercalcemia. However, asymptomatic primary hyperparathyroidism with mild hypercalcemia and renal and bone status close to normal is now the more common picture of the disease and in this situation conservative management can be considered, because many of those patients may have a prolonged benign course. Management guidelines are therefore devised to minimize the risk for deterioration of renal, skeletal or gastrointestinal complications of hyperparathyroidism. General medical management includes recommendation to avoid dehydration, immobilization or excessive dietary calcium intake and therapy with thiazides; intravenous infusion with isotonic saline combined to furosemide or etacrinic acid are recommended to treat acute or threatening hypercalcemia. Many other drugs as phosphate, mithramycin, gallium nitrate and calcitonin have been reported to be useful in reversing hypercalcemia but their transient effects, toxicity and side effects limit their clinical use. The bisphosphonates, a new class of bone resorption inhibitors, have been shown to be particularly safe so they result especially effective on controlling acute hypercalcemia and on preventing "hungry bone" disease. However, their effect is not sustained because the serum calcium tends to return toward pretreatment levels despite continued therapy; therefore their consistent beneficial effect on long-term treatment seems unlike.