Recent revisions in the management guidelines of primary hyperparathyroidism (pHPT) have pointed towards greater utilization of parathyroidectomy1. While the benefits of surgical intervention have been well demonstrated, for some patients – particularly high-risk or elderly – surgery may not be viable as the potential risks are perceived to outweigh expected benefits. This study aims to evaluate the outcomes of medical follow-up compared to parathyroidectomy over 24 months in patients deemed ineligible for surgery based on age and co-morbidity.
Between 2013-2016, 329 inpatients were diagnosed with pHPT at a major tertiary centre. All 48 patients (14.6%) managed conservatively with medical therapy, and 48 age-matched surgical controls receiving parathyroidectomy, were included in this study.
Serum concentrations of calcium, vitamin D and creatinine, estimated glomerular filtration rate, and femoral neck BMD T-scores were compared at baseline and following treatment to assess for differences longitudinally and between groups. The median follow-up time was 24 months (range 6-36).
Mean serum calcium levels were lower in surgical patients compared to medically treated patients at 3, 6, 9, 12, 18, 24 months (all p<0.001) and 36 months (p=0.055). Medically treated patients however, maintained a stable serum calcium over 36 months. Baseline vitamin D status had no impact on serum calcium levels in either group. Although the medical group had slightly poorer renal function, this was not statistically significant and did not worsen over 36 months. There was a trend towards improvement in femoral neck BMD T-score with parathyroidectomy (mean 0.57g/cm2, p=0.102), while BMD appeared to remain stable with medical therapy.
Although there is significant benefit with regards to serum calcium and a trend to improvement in BMD for operative cure of hyperparathyroidism, conservative medical management appears to not be associated with worsening serum calcium, renal function, or a decline in BMD over twenty-four months.