Guideline name: Hyperparathyroidism (primary): diagnosis, assessment and initial management [NG132]
Update type: New guideline
Published: May 2019
- NICE has published a new guideline which focuses on the diagnosis, assessment and management of primary hyperparathyroidism, with the aim of reducing long-term complications and improving quality of life.
- Measurement of albumin-adjusted serum calcium and parathyroid hormone (PTH) are crucial in the diagnosis of the condition in primary care.
Diagnosis in primary care
Albumin-adjusted serum calcium
- Measure albumin-adjusted serum calcium if any of the following criteria are present
- Hypercalcaemia symptoms (thirst, frequent or excessive urination, or constipation).
- Osteoporosis or a previous fragility fracture.
- Renal calculi.
- Incidental finding of elevated albumin-adjusted serum calcium (≥2.6 mmol/L or above).
- Measure albumin-adjusted serum calcium for individuals with chronic non-differentiated symptoms.
- Measurement of ionised calcium is not recommended.
- If the initial albumin-adjusted serum calcium level is ≥2.6 mmol/L or ≥2.5 mmol/L along with features of primary hyperparathyroidism, at least 1 more repeat measurement is necessary. Consider further measurements on the basis of symptoms and albumin-adjusted serum calcium levels.
- Measure PTH using a random sample and concurrently measure albumin-adjusted serum calcium.
- Repeated PTH measurement is not routinely recommended in primary care.
- Seek specialist advice if PTH measurement is either:
- Above the midpoint of reference range with suspicion of primary hyperparathyroidism or
- Below the midpoint of reference range with albumin-adjusted serum calcium level ≥2.6 mmol/L.
- Further investigations are not recommended if:
- PTH is within reference range but below the midpoint and
- Albumin-adjusted serum calcium level is
- If PTH is below the lower limit of the reference range, seek alternative diagnoses including malignancy.
Assessment in secondary care
- If there is a probable diagnosis of primary hyperparathyroidism, measure vitamin D and offer vitamin D supplements if required.
- Urine calcium excretion should be measured to rule out familial hypocalciuric hypercalcaemia
- If a diagnosis of primary hyperparathyroidism is confirmed, perform the following:
- Assessment of symptoms and comorbidities.
- Measurement of estimated GFR or serum creatinine.
- Dual-energy X-ray absorptiometry scan of the lumbar spine, distal radius and hip.
- Ultrasound scan of the renal tract.
Referral for surgery
- Individuals with a confirmed diagnosis of primary hyperparathyroidism can be referred to a surgeon specialising in parathyroid surgery if the following criteria are present:
- Symptoms of hypercalcaemia (thirst, frequent or excessive urination, or constipation) or
- End-organ disease (renal stones, fragility fractures or osteoporosis) or
- Albumin-adjusted serum calcium level ≥2.85 mmol/L.
- Surgical options include 4-gland exploration and focused parathyroidectomy.
- Measure albumin-adjusted serum calcium and PTH prior to discharge post-surgery and albumin-adjusted serum calcium 3 to 6 months after surgery to assess the success of the surgery.
- If surgery is unsuccessful, unsuitable or has been declined by patient, consider treatment with cinacalcet, provided albumin-adjusted serum calcium level is
- ≥2.85 mmol/L with symptoms of hypercalcaemia or
- ≥3.0 mmol/L without symptoms of hypercalcaemia.
- The decision to continue cinacalcet should be based on the extent of reduction of symptoms and albumin-adjusted serum calcium level.
- Bisphosphonates can lower the risk of fractures in at-risk patients with primary hyperparathyroidism.
- Bisphosphonates are not recommended for chronic hypercalcaemia of primary hyperparathyroidism.
- If parathyroid surgery was successful:
- Measure albumin-adjusted serum calcium once a year.
- Seek specialist opinion if osteoporosis is present.
- Seek specialist opinion if renal stones are present.
- If parathyroid surgery was not performed or it was unsuccessful:
- Measure albumin-adjusted serum calcium and eGFR or serum creatinine once a year. If treated with cinacalcet, follow monitoring guidelines prescribed in the summary of product characteristics.
- Conduct a DXA scan at diagnosis and every 2 to 3 years.
- Offer ultrasound of the renal tract at diagnosis, if renal stone is suspected.
- Parathyroid surgery is suitable for women with primary hyperparathyroidism who are considering pregnancy.
- Consult a multidisciplinary team (MDT) in a specialist centre for management of primary hyperparathyroidism during pregnancy. The MDT should comprise an obstetrician, a physician specialising in primary hyperparathyroidism, a surgeon, a midwife, and an anaesthetist.
- Cinacalcet and bisphosphonates are not recommended for pregnant women with primary hyperparathyroidism.
- Women with primary hyperparathyroidism have an increased risk for hypertensive disease in pregnancy. Follow NICE guideline on hypertension in pregnancy.
Information and support
- Provide patients with primary hyperparathyroidism all the necessary information regarding the condition and treatments options
- Provide advice to patients with primary hyperparathyroidism regarding symptom reduction, and preparation for surgery or other treatments.
- Discuss ongoing care and monitoring with patients.