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Learning Objectives Hyperparathyroidism

  • Learn how to diagnose primary hyperparathyroidism.

  • Evaluate when treatment may be needed in primary hyperparathyroidism.

  • Understand the role of medical versus surgical therapy in primary hyperparathyroidism.

Paget Disease of Bone
  • Learn how to diagnose and monitor Paget disease of bone.

  • Understand when treatment is indicated in Paget disease of bone.

Key Clinical Points Hyperparathyroidism

  1. Primary hyperparathyroidism is often asymptomatic and is detected using routine laboratory tests.

  2. When primary hyperparathyroidism is symptomatic, the most common presentation in those over the age of 61 involves nephrolithiasis, fatigue, and bone disease.

  3. Observation may be appropriate in some patients.

  4. Surgical treatment should be considered if the patient is symptomatic and/or there are signs of end-organ damage.

  5. Medical treatment with a bisphosphonate and/or cinacalcet may be an option for nonsurgical candidates who require intervention.

Paget Disease of Bone
  1. Paget disease of bone is a focal disorder of osteoclasts resulting in increased bone turnover and lytic skeletal lesions that primarily affects older individuals.

  2. Paget disease is often asymptomatic, but can cause bone and joint pain. A therapeutic trial of bisphosphonates may aid in distinguishing bone pain from nonbone pain.

  3. Observation and supportive measures may be appropriate for many patients with Paget disease of bone.

  4. When treatment is indicated, the treatment of choice for Paget disease is an intravenous (IV) infusion of zoledronate 5 mg over 15 minutes. Treatment is targeted to achieve a serum alkaline phosphatase in the lower half of the normal reference range.

  5. Treatment can normalize bone turnover markers and decrease bone pain; however, there is no evidence that this results in improved long-term outcomes such as prevention of fractures or deformity.


Background and Epidemiology

Hyperparathyroidism is a common disorder of calcium, phosphorus, and bone metabolism caused by increased circulating levels of parathyroid hormone (PTH). This disease is important to geriatricians because its incidence increases with age, and it is most common in older people. Hyperparathyroidism is considered primary when hypersecretion of PTH is caused by a fundamental defect of the parathyroid glands resulting from a single parathyroid adenoma, diffuse hyperplasia, multiple adenomas, or, rarely, a parathyroid carcinoma. Secondary hyperparathyroidism occurs when there is a hypocalcemic stimulus, as in cases of vitamin D deficiency or chronic renal failure that results in parathyroid stimulation. Tertiary hyperparathyroidism occurs in patients with chronic secondary hyperparathyroidism who develop autonomous hypersecretion of PTH and hypercalcemia, for example, patients with end-stage renal disease. This chapter focuses on primary hyperparathyroidism.

The incidence of primary hyperparathyroidism in the United States is approximately 1 per 1000. The Rochester Epidemiological Project reported that the peak incidence of primary hyperparathyroidism is 63.2 per 100,000 person-years at ages 65 to 74. Primary hyperparathyroidism can affect both genders at any age; however, the disease affects women more than men by almost 2:1, and in women, it most often occurs in the first decade after menopause. According to ...

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