Intended for healthcare professionals

Clinical Review

Diagnosis and management of primary hyperparathyroidism

BMJ 2012; 344 doi: (Published 19 March 2012) Cite this as: BMJ 2012;344:e1013
  1. Shelley Pallan, third year internal medicine resident1,
  2. Mohammed Omair Rahman, MSc student2,
  3. Aliya A Khan, clinical professor of medicine 3
  1. 1Department of Medicine, McMaster University, Hamilton, ON Canada,
  2. 2Faculty of Health Sciences, McMaster University, ON Canada
  3. 3McMaster University, Hamilton, ON, Canada
  1. Correspondence to: A Khan aliya{at}
  • Accepted 14 December 2011

Summary points

  • Primary hyperparathyroidism (PHPT) is the most common cause of hypercalcaemia in the ambulatory setting; malignancy and other secondary causes must be excluded

  • Primary hyperparathyroidism is diagnosed when intact parathyroid hormone is raised or mid to high normal in the setting of raised total or ionised calcium after exclusion of conditions that mimic PHPT

  • Medical surveillance comprises annual measurement of serum calcium and creatinine, plus measurement of bone mineral density (at three sites) every one to two years

  • Medical management options for select patients and those who do not meet parathyroidectomy guidelines include bisphosphonates and oestrogen replacement (both provide skeletal protection) and the calcimimetic cinacalcet, which can reduce serum calcium and parathyroid hormone values

  • Sestamibi imaging is used for localisation before surgery and is not a diagnostic tool—a negative scan does not exclude the diagnosis of PHPT

  • Secondary hyperparathyroidism is commonly caused by vitamin D inadequacy or chronic kidney disease

Primary hyperparathyroidism is the most common cause of hypercalcaemia in the ambulatory setting.1 2 Although this condition can occur at any age, it commonly affects people over the age of 50 years and postmenopausal women.2 3 Over the past few decades it has changed from being a condition usually defined by its symptoms to one that is often discovered on routine screening tests while the patient is still largely asymptomatic. In light of advances in research, new guidelines on the diagnosis and management of asymptomatic primary hyperparathyroidism have recently been developed. We review the presentation, diagnosis, and management of primary hyperparathyroidism for the generalist doctor, with evidence drawn from randomised controlled trials, cohort studies, and the most recent consensus guidelines.

Sources and selection criteria

We searched Medline from 2002 to 2011 using the terms “primary hyperparathyroidism”, “diagnosis”, and “management of primary hyperparathyroidism”. We reviewed all relevant articles as well as the proceedings from …

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