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Endocrinology & Metabolic

Hyperparathyroidism

Hyperparathyroidism is excessive parathyroid hormone secretion: primary disease causes hypercalcaemia through autonomous gland activity, while secondary disease is an appropriate response to chronic kidney disease or vitamin-D deficiency and tertiary disease becomes autonomous after prolonged stimulation.

In a nutshell

Primary hyperparathyroidism gives high calcium with an inappropriately non-suppressed PTH; secondary disease gives high PTH with low or normal calcium, usually from kidney disease or vitamin-D deficiency; tertiary disease becomes autonomous after longstanding secondary stimulation. Exclude FHH before surgery, refer for parathyroidectomy when NICE criteria are met, and treat acute severe hypercalcaemia as an emergency.

Classic presentation

An incidental persistent calcium elevation with PTH that is high or not suppressed, often in a patient with renal stones, osteoporosis or few symptoms.

Key points

  • Repeat albumin-adjusted calcium and measure PTH concurrently.
  • Assess renal function, vitamin D, urinary calcium, bone density and renal tract complications.
  • A low urinary calcium suggests FHH, which usually does not benefit from surgery.
  • Localisation scans support operative planning; they do not establish the biochemical diagnosis.
  • NICE supports surgery for symptomatic/end-organ disease or adjusted calcium at least 2.85 mmol/L, and consideration even without these features.

First-line investigation

Repeat albumin-adjusted calcium with concurrent PTH, renal function, phosphate, vitamin-D assessment and medication review.

Management

Identify the emergency

  • Escalate adjusted calcium above 3.5 mmol/L, severe symptoms, rapid deterioration, dehydration, acute kidney injury or dysrhythmia for urgent hospital treatment.2

Confirm the biochemical phenotype

  • Repeat adjusted calcium with concurrent PTH, then check phosphate, renal function, vitamin D, medicines and urinary calcium where primary disease is suspected.1

Refer for surgery when indicated

  • Refer symptomatic, complicated or biochemically severe primary hyperparathyroidism for parathyroidectomy; consider referral even without those features.1

Protect kidney and bone

  • Assess renal stones/function and bone density; address vitamin-D deficiency and other contributors with specialist oversight.1

Use medical treatment selectively

  • Use cinacalcet when NICE criteria are met and surgery is unsuitable, and use antiresorptive treatment for selected fracture-risk indications with current BNF checks.1,3

Monitor cure or persistence

  • Monitor conservatively managed disease; after surgery check calcium/PTH before discharge and calcium at 3 to 6 months, then annually when appropriate.1

Exam traps

  • A normal-range PTH is inappropriate when calcium is high.
  • Do not diagnose primary hyperparathyroidism from one calcium result alone.
  • Do not operate on suspected FHH without resolving the diagnostic uncertainty.
  • A negative sestamibi scan does not exclude hyperparathyroidism.
  • Cinacalcet lowers calcium but is not a substitute for definitive surgery when surgery is appropriate.

Illustrations

Tc-99m sestamibi with SPECT-CT showing focal retained tracer in an ectopic mediastinal parathyroid adenomaA technetium-99m sestamibi parathyroid scan showing focal retained tracer corresponding to a hyperfunctioning parathyroid adenoma; localisation is for operative planning rather than diagnosis.Weibin Zhou, MD, PhD, Min Chen, MM, Wikimedia Commons · CC-BY-SA-4.0
Brown tumours of the handsBilateral hand radiographs showing expansile lucent brown tumours associated with severe long-standing hyperparathyroid bone disease.Frank Gaillard, Wikimedia Commons · CC-BY-SA-3.0

Key sources

  1. NICE NG132: Hyperparathyroidism (primary): diagnosis, assessment and initial management (Current NICE recommendations on repeat albumin-adjusted calcium, concurrent PTH, vitamin-D assessment, FHH exclusion, organ assessment, surgery, cinacalcet, bisphosphonates and follow-up; accessed 4 August 2026.)Updated 23 May 2019
  2. Society for Endocrinology: emergency management of acute hypercalcaemia in adults (UK emergency guidance covering severity, ECG, saline rehydration, bisphosphonates, specialist rescue measures and dialysis; accessed 4 August 2026.)Updated 5 Oct 2016
  3. British National Formulary (BNF) (Current UK prescribing information for cinacalcet, bisphosphonates, calcitonin, denosumab and intravenous fluids; product-specific dose, renal and monitoring details must be checked at the point of care; accessed 4 August 2026.)

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.