Hypercalcaemia and primary hyperparathyroidism

Hypercalcaemia is most commonly caused by primary hyperparathyroidism (PHPT) or malignancy. PHPT is common, affects women more than men, and is usually caused by a solitary parathyroid adenoma. The most common presentation is an asymptomatic incidental finding on blood tests performed for another indication. The only curative treatment is parathyroidectomy. In 2014, the Fourth International Workshop on the management of asymptomatic PHPT updated its guidance on the management of asymptomatic PHPT. It recommended surgery in: all symptomatic patients; asymptomatic patients with hypercalcaemia >0.25 mmol/litre above the upper limit of the reference range, evidence of end-organ damage, including impaired renal function, reduced bone mineral density, established vertebral fractures and hypercalciuria; and patients <50 years old. In other patients with PHPT, conservative management with regular monitoring is an acceptable management strategy. Defining ‘asymptomatic’ is not always easy, and there is growing awareness of the prevalence of reduced quality-of-life scores among patients with ‘asymptomatic’ PHPT; however, there is a lack of definitive evidence showing benefit in these domains following parathyroidectomy. Therefore, careful clinical decision-making is required in this group of patients.