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Primary hyperparathyroidism with osteoporosis — SCE Rheumatology MCQ

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ModerateMetabolic Bone DiseasePrimary hyperparathyroidism with osteoporosisSCE Rheumatology

A 76-year-old woman has confirmed primary hyperparathyroidism. Her albumin-adjusted serum calcium has been 2.89–2.93 mmol/L on three measurements, with an inappropriately raised parathyroid hormone concentration. She has no thirst, polyuria, constipation, renal calculi or previous fragility fracture. Her eGFR is 62 mL/min/1.73 m², 25-hydroxyvitamin D is replete, and DXA shows a lumbar-spine T-score of −2.9. Following endocrine and surgical assessment, parathyroidectomy is considered unsuitable because of severe cardiorespiratory comorbidity. Which is the most appropriate pharmacological management strategy?

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Correct answer: D — Start bisphosphonate therapy for fracture-risk reduction and continue biochemical monitoring

This patient has primary hyperparathyroidism with osteoporosis, but surgery has been judged unsuitable. NICE recommends considering a bisphosphonate in primary hyperparathyroidism when fracture risk is increased. Its purpose is skeletal protection rather than long-term correction of hypercalcaemia. She should also undergo ongoing monitoring, including annual albumin-adjusted calcium and renal function, with DXA generally considered every 2–3 years in non-operated patients. Cinacalcet is not currently indicated. When surgery is unsuccessful, unsuitable or declined, NICE recommends considering it at an adjusted calcium of at least 2.85 mmol/L only when hypercalcaemic symptoms are present, or at at least 3.0 mmol/L irrespective of symptoms. Her calcium is below 3.0 mmol/L and she is asymptomatic. Consequently, combined therapy is also unnecessary at this stage. Osteoporosis and an adjusted calcium of at least 2.85 mmol/L are indications for surgical referral, but she has already undergone appropriate multidisciplinary assessment and surgery is unsuitable. Surveillance alone would neglect her elevated fracture risk. Although bisphosphonates may improve bone mineral density, they should not be presented as treatment for the chronic hypercalcaemia of primary hyperparathyroidism.

Reference: Hyperparathyroidism (primary): diagnosis, assessment and initial management — Recommendations (Published 23 May 2019; checked 19 August 2026) — https://www.nice.org.uk/guidance/ng132/chapter/Recommendations Hyperparathyroidism (primary): diagnosis, assessment and initial management — Recommendations (Published 23 May 2019; checked 19 August 2026) — https://www.nice.org.uk/guidance/ng132/chapter/Recommendations