A must review for any general Endocrinologist who treats hyperparathyroidism - which is most. Briefly: 116 patients with PHPT (66 post-menopausal F, 25 pre-menopausal F, 25 men) were studied. 59 patients had surgery (50 asymptomatic[asx], 9 symptomatic) and 57 did not have surgery (29 had not met surgical criteria[sc], 20 met sc but refused surgery).A picture tells a thousand words. Above: the observation graph shows those who did not have surgery over a 15 year period (n = number of patients remaining in the study), the parathyroidectomy group obviously had the surgery. Z scores are compared. (*p<0.05 compared to baseline)
Baseline calcium (10.5 vs 10.8), PTH (116 vs 144), Z score lumb spine (-0.03 vs -0.8), and Z score fem neck (-0.63 vs -1.22) differed significantly at baseline between the no surgery vs surgical group.
Notably in those followed without surgery, calcium was signigicantly higher at year 15 vs baseline (11.1 vs 10.5), but not PTH or urinary calcium.
Unfortunately, the numbers are too small to draw any meaningful conclusions about fracture rates. This change in DEXA scores is food for thought though when deciding about surgical parathyroidectomy for asymptomatic patients. It would have been nice to see the changes in BMD split out for post-menopausal, pre-menopausal and men.
Dr. Laidlaw,
ReplyDeleteNice post.
This raises some interesting questions.
I have a 78 year old male and healthy with a normal calcium with very high PTH.
I had recommended just monitoring. I had only monitored his vertebral DEXA. Maybe I need to also look at the other sites such as the femoral neck and radius, as these are the cortical bone areas which are involved in PTH induced bone loss.
I have a similar case which I was going to post separately, but briefly: 66 yo female
ReplyDeleteDEXA: T scores -2.7, -2.8, -4.7 in the left femoral neck, right femoral neck, lumbar spine respectively. Ca 9.9, PTH 161. Vit D <7.
I went ahead and corrected Vit D first, but there was no change in iPTH. Parathyroid scintigraphy showed probable adenoma in the lower left neck. I went ahead and referred her for surgery.
She told me that she's had osteoporosis for 15 years, but nobody had done a workup. Ironically, she came in originally inquiring about Forteo.