How should I manage a patient with asymptomatic primary hyperparathyroidism, and when should I consider surgical intervention?

Management of a patient with asymptomatic primary hyperparathyroidism involves regular monitoring and assessment rather than immediate surgery. This includes annual measurement of serum calcium, vitamin D levels with supplementation if needed, estimated glomerular filtration rate (eGFR), and creatinine. Bone mineral density should be assessed by dual-energy X-ray absorptiometry (DXA) every 2 years, and renal imaging should be performed if renal stones are suspected. Cardiovascular risk assessment is also recommended. Patients should be provided with information about their condition, symptoms to watch for, and lifestyle advice including hydration, diet, and exercise to reduce symptoms and prepare for possible future treatment ¹,².

Surgical intervention (parathyroidectomy) should be considered and referral to a surgeon with expertise in parathyroid surgery is recommended if any of the following are present: symptoms of hypercalcaemia (such as thirst, frequent urination, or constipation), evidence of end-organ disease (renal stones, fragility fractures, or osteoporosis), or an albumin-adjusted serum calcium level of 2.85 mmol/L or above. Surgery may also be considered even in the absence of these features, based on clinical judgement and patient preference ²,¹.

Preoperative imaging (usually ultrasound and sestamibi scan) is offered to guide surgical approach, but surgery should proceed even if imaging does not identify a single adenoma, with 4-gland exploration performed by an experienced surgeon. Patients should be informed about the types of surgery, risks, benefits, and expected outcomes to support shared decision-making ².