AAES GUIDELINES 3:

INDICATIONS AND OUTCOMES OF INTERVENTION

 

RECOMMENDATION: Parathyroidectomy is indicated, and is the preferred treatment, for all patients with symptomatic pHPT.

 

COMMENT: This is a major policy statement which represents a change from previous guidelines issued by other groups such as the NIH. It represents an understanding  and analysis of newer evidence that pHPT leads to progressive end-organ damage in most patients. Even those previously considered “asymptomatic”. most likely have subtle symptoms or potential end-organ damage and require treatment.  This includes bone mineral density loss with osteoporosis, increased risk of hypertension, cardiovascular disease and heart attack, cerebrovascular disease, neurocognitive impairment as well as neuropsychiatric disturbances, muscle weakness and fatigue, kidney stones and renal impairment, fibromyalgia and musculoskeletal pain.  Untreated pHPT is also associated with a significantly increased risk of early death. Although the degree to which surgery and cure of pHPT is able to significantly reverse any established effects has not yet been proven, it is intuititive that early surgery, once the diagnosis of pHPT has been made, should be recommended rather than waiting until end-organ damage is established

 

RECOMMENDATION: Parathyroidectomy is indicated when the serum calcium level is greater than 1 mg/dl above normal, regardless of whether objective symptoms are present or absent.

 

COMMENT: There is no point in waiting for the serum calcium to rise to a high level as end-organ damage can occur early in the disease process, even with normal calcium levels.

 

RECOMMENDATION: Parathyroidectomy is indicated for objective evidence of renal involvement, including nephrolithiasis (clinically apparent or on renal imaging), nephrocalcinosis, or impaired renal function (GFR < 60 cc/min)

 

COMMENT: Any evidence of kidney damage requires early surgery

 

RECOMMENDATION: Parathyroidectomy is indicated when there is objective evidence of skeletal involvement including osteoporosis by World Health Organization DXA criteria (T-Score < -2.5) at any site, history of fragility fracture, or evidence of vertebral compression fracture on imaging of the spine.

 

COMMENT: Loss of bone mineral density and osteoporosis is now the commonest indication for parathyroidectomy as it is not treatable condition whilst the adenoma remains in situ. Fortunately in 95% of cases the bone remineralizes after surgery and the osteoporosis is cured.

 

RECOMMENDATION:  Parathyroidectomy is indicated when pHPT is diagnosed at ≤50 years regardless of whether objective or subjective symptoms are present or absent

 

COMMENT: The younger the patient, the more reason to have surgery to avoid end-organ damage

 

RECOMMENDATION:  Parathyroidectomy is indicated when the clinical or biochemical evidence is consistent with parathyroid carcinoma

 

COMMENT: Parathyroid cancer is very rare (<1%) and can often be suspected on presentation (very high serum calcium or PTH or a large palpable tumor). Clearly surgery should be undertaken as soon as possible.

 

RECOMMENDATION: Parathyroidectomy is recommended for patients with neurocognitive and/or neuropsychiatric symptoms that may be attributable to pHPT

 

COMMENT: Neurocognitive and neuropsychiatric disturbances include easy fatigability, lassitude, depression, anxiety, irritability, cognitive impairment and disordered sleep. A substantial body of literature now confirms that parathyroidectomy is associated with some degree of improvement in these symptoms.  Clearly a “cure” of long standing symptoms, eg life-long depression, is not guaranteed with surgery, but there may be a substantive mood improvement. The most dramatic improvements are seen with disturbed sleep patterns and fatigability

 

RECOMMENDATION: Parathyroidectomy should be offered to surgical candidates with cardiovascular disease and who might benefit from mitigation of potential cardiovascular sequelae other than hypertension

 

COMMENT: Patients with pHPT have more severe cardiovascular disease and a significantly increased death rate from cardiac events. There is an increased incidence of myocardial infarction, hypertension, stroke, congestive heart failure, and diabetes with pHPT, which may improve with surgery. Long-standing hypertension tends not to improve however, presumably due to increased stiffness of the vessel walls associated with high calcium levels.

 

RECOMMENDATION: The non-traditional symptoms of muscle weakness, functional capacity, and abnormal sleep patterns should be considered in the decision for parathyroidcetomy.

RECOMMENDATION: The non-traditional symptoms of gastrointestinal refills and fibromyalgia may be considered in the decision for parathyroidectomy.   

 

COMMENT: There is not yet good data to show that non-traditional  including muscle strength, functional capacity, digestive symptoms, and fibromyalgia symptoms improve with surgery.

 

RECOMMENDATION: Parathyroid surgery should be conducted by surgeons with adequate training and experience.

 

COMMENT: For experienced parathyroid surgeons, the expected cure rate for  pHPT is >95%whereas the published success rate for surgeons who performed <10 parathyroidectomies per year is considerably lower, at approximately 70%.  Patients with pHPT shoul be referred to an experienced parathyroid surgeon rather than a low volume general or ENT surgeon who may only perform a few parathyroid operations each year.

 

RECOMMENDATION:  Operative management is more cost-effective than long-term observation or pharmacologic therapy

 

COMMENT: Numerous studies demonstrate that observation alone or medical treatment with Sensipar is simply neither effective nor cost-effective therapy compared to surgery