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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EPrimary Hyperparathyroidism (PHPT) is a common disorder, and surgery is a curative option for patients whose PHPT is symptomatic, unless there is a contraindication. The Guidelines for the Management of Asymptomatic PHPT are reviewed in this article.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Ethyroid disorders\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ediabetes \u0026amp; endocrinology guidelines\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \n         \u003Cp id=\u0022p-2\u0022\u003EThe Guidelines for the Management of Asymptomatic Primary Hyperparathyroidism (PHPT) [Bilezikian JP et al. \u003Cem\u003EJ Clin Endocrinol Metab\u003C\/em\u003E 2014] were reviewed by John P. Bilezikian, MD, Columbia University College of Physicians and Surgeons, New York, New York, USA. PHPT is a common disorder, and surgery is a curative option for patients whose PHPT is symptomatic, unless there is a contraindication. For patients with asymptomatic PHPT, these evidence-based guidelines are intended to provide guidance to determine whether a surgical or medical approach should be used for management.\u003C\/p\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EThe development of the 2014 Guidelines was the objective of the 4th International Workshop on the Management of Asymptomatic PHPT, which was held in Florence, Italy, in September 2013. Four working groups focused on diagnosis, presentation, surgical management, and medical management, and a document on each of these areas will be published. A complete review of the peer-reviewed literature since 2008 served as the foundation for the evidence-based recommendations in the revised 2014 Guidelines.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EDIAGNOSIS AND ASSESSMENT OF ASYMPTOMATIC PHPT\u003C\/h2\u003E\n         \u003Cp id=\u0022p-4\u0022\u003ENormocalcemic PHPT is now recognized as a phenotype of PHPT, and its management approach is shown in \u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E [Bilezikian JP et al. \u003Cem\u003EJ Clin Endocrinol Metab\u003C\/em\u003E 2014]. In this phenotype, the initial presentation may be only elevated parathyroid hormone (PTH) levels.\u003C\/p\u003E\n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/20\/18\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Management of Asymptomatic Normocalcemic PHPT\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-2050500295\u0022 data-figure-caption=\u0022Management of Asymptomatic Normocalcemic PHPT\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/20\/18\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/20\/18\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/20\/18\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/16434\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-5\u0022 class=\u0022first-child\u0022\u003EManagement of Asymptomatic Normocalcemic PHPT\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EBMD=bone mineral density; DXA=dual-energy X-ray absorptiometry; PHPT=primary hyperparathyroidism; PTH=parathyroid hormone.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EReproduced with permission from JD Bilezikian, MD.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-6\u0022\u003EA new hypothesis in the 2014 Guidelines states that PHPT is characterized by compromised cortical and trabecular compartments and an increased risk of fracture, even in asymptomatic PHPT. A skeletal assessment of PHPT is recommended; this includes dual-energy X-ray absorptiometry (DXA), and either vertebral fracture assessment (VFA), trabecular bone score (TBS), or vertebral X-rays. Recent studies showed that the majority of patients with asymptomatic PHPT had abnormal trabecular structure as measured by TBS [Silva BC et al. \u003Cem\u003EJ Clin Endocrinol Metab\u003C\/em\u003E 2013; Romagnoli E et al. \u003Cem\u003EBone\u003C\/em\u003E 2013]. Vertebral fractures are increased in PHPT, as shown by clinical studies [Vignali E et al. \u003Cem\u003EJ Clin Endocrinol Metab\u003C\/em\u003E 2009; Mosekilde L. \u003Cem\u003EClin Endocrinol (Oxf)\u003C\/em\u003E 2008], as are microstructural deficits [Hansen S et al. \u003Cem\u003EJ Bone Miner Res\u003C\/em\u003E 2012; Stein EM et al. \u003Cem\u003EJ Bone Miner Res\u003C\/em\u003E 2013].\u003C\/p\u003E\n         \u003Cp id=\u0022p-7\u0022\u003ERenal assessment of PHPT is recommended in the 2014 Guidelines to include 24 h urine analysis for calcium and other stone risk factors, and abdominal imaging. In patients with PHPT and an estimated glomerular filtration rate (eGFR) \u0026lt; 60 cc\/min, there was evidence of more skeletal involvement, including altered bone remodeling [Walker MD et al. \u003Cem\u003EJ Clin Endocrinol Metab\u003C\/em\u003E 2012]. Kidney stones are the most common complication of PHPT and can be detected by noninvasive imaging.\u003C\/p\u003E\n         \u003Cp id=\u0022p-8\u0022\u003EThe current data for the effect of PHPT on the neurocognitive and cardiovascular systems are insufficient to make recommendations for its surgical management, according to the 2014 Guidelines. It is known that the clinical manifestations of PHPT may be more severe in the presence of vitamin D deficiency; thus, the 2014 Guidelines recommend 25-OH vitamin D levels \u0026gt; 20 ng\/mL, whereas calcium intake should follow the national guidelines, stated Dr. Bilezikian.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ESURGICAL MANAGEMENT OF PHPT\u003C\/h2\u003E\n         \u003Cp id=\u0022p-9\u0022\u003EPreoperative localization of the parathyroid, using computed tomography, ultrasound, or sestamibi scintigraphy, is mandatory before surgery. Surgical approaches are full exploration or a minimally invasive parathyroidectomy with intraoperative assessment of PTH levels, according to the 2014 Guidelines.\u003C\/p\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EThe levels of PTH return to normal after successful parathyroid surgery, and other biochemical indices improve, including calcium, 25-OH and 1,25-OH vitamin D, urinary calcium, and markers of bone resorption and formation. An observational study of 116 patients showed that bone density increased at the lumbar spine, femoral neck, and distal radius after parathyroid surgery (\u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E) [Rubin MR et al. \u003Cem\u003EJ Clin Endocrinol Metab\u003C\/em\u003E 2008].\u003C\/p\u003E\n         \u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/20\/18\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Improvements in Bone Density After Parathyroid Surgery\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-2050500295\u0022 data-figure-caption=\u0022Improvements in Bone Density After Parathyroid Surgery\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/20\/18\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/20\/18\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/20\/18\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/16435\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \n               \u003Cp id=\u0022p-11\u0022 class=\u0022first-child\u0022\u003EImprovements in Bone Density After Parathyroid Surgery\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-3\u0022\u003E*p \u0026lt; .05, compared with baseline.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-4\u0022\u003EReproduced from Rubin MR et al. The Natural History of Primary Hyperparathyroidism with or without Parathyroid Surgery after 15 Years. \u003Cem\u003EJ Clin Endocrinol Metab\u003C\/em\u003E. September 2008;93(9):3462\u20133470. With permission from The Endocrine Society.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-4\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EMEDICAL MANAGEMENT OF PHPT\u003C\/h2\u003E\n         \u003Cp id=\u0022p-12\u0022\u003EObservation is one element of the medical management of PHPT. An observational study of the natural history of PHPT showed that 37% of the asymptomatic patients developed \u2265 1 indication (hypercalcemia, hypercalciuria, or reduced bone mineral density [BMD]) for parathyroid surgery during a 15-year period [Rubin MR et al. \u003Cem\u003EJ Clin Endocrinol Metab\u003C\/em\u003E 2008]. The natural history of biochemical indices for PHPT in patients who did not have surgery is shown in \u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E.\u003C\/p\u003E\n         \u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/16436\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/16436\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/16436\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-13\u0022 class=\u0022first-child\u0022\u003EEvolution in Biochemical Indices in PHPT During a 15-Year Period\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-17\u0022\u003EPharmacological treatment in PHPT includes cinacalcet plus bisphosphonates in patients with severe hypercalcemia and low BMD, or cinacalcet alone for severe hypercalcemia. Several approaches that are not approved by the United States Food and Drug Administration were also mentioned: estrogen plus raloxifene, bisphosphonates alone for low BMD, and denosumab.\u003C\/p\u003E\n         \u003Cp id=\u0022p-18\u0022\u003EEstrogen and raloxifene in combination have been shown to lower serum calcium and have a neutral effect on BMD and PTH. The bisphosphonate alendronate has been shown to have a neutral effect on serum calcium and PTH, and to increase BMD [Khan AA et al. \u003Cem\u003EJ Clin Endocrinol Metab\u003C\/em\u003E 2004]. Cinacalcet lowered serum calcium and PTH, and it had a neutral effect on BMD [Peacock M et al. \u003Cem\u003EJ Clin Endocrinol Metab\u003C\/em\u003E 2005]. Cinacalcet plus a bisphosphonate were shown to lower serum calcium and PTH, and to increase BMD [Faggiano A et al. \u003Cem\u003EEndocrine\u003C\/em\u003E 2011].\u003C\/p\u003E\n         \u003Cp id=\u0022p-19\u0022\u003EThe 2014 Guidelines recommend monitoring of serum calcium annually, as the 2009 Guidelines did [Bilezikian JP et al. \u003Cem\u003EJ Clin Endocrinol Metab\u003C\/em\u003E 2009]. The skeletal assessment with DXA every 1 or 2 y is also unchanged, but with the addition of computed tomography or VFA if clinically indicated; renal creatinine clearance assessment is still recommended annually, with the addition of a stone risk profile or abdominal imaging if clinically indicated.\u003C\/p\u003E\n         \u003Cp id=\u0022p-20\u0022\u003EDr. Bilezikian stated that although the balance of evidence is leaning toward surgery as being the best option for patients with asymptomatic PHPT, both surgical and medical management should be considered for every patient.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2014 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/14\/20\/18.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzm0k2\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzm0k2\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzm0k2\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}