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This guideline summary only covers diagnostic testing in primary care, monitoring, pregnancy, and information and support. Please refer to the full guideline for the complete set of recommendations.

Contents not included in this summary

1.2 Testing and assessment in secondary care

1.3 Referral for surgery

1.4 Surgical management

1.5 Non-surgical management

1.8 Information and support

Terms used in this guideline

1.1 Diagnostic testing in primary care

Measuring albumin-adjusted serum calcium

1.1.1 Measure albumin-adjusted serum calcium for people with any of the following features, which might indicate primary hyperparathyroidism:

  • symptoms of hypercalcaemia, such as thirst, frequent or excessive urination, or constipation
  • osteoporosis or a previous fragility fracture (for recommendations on assessing the risk of fragility fracture in people with osteoporosis, see the NICE guideline on osteoporosis)
  • a renal stone (for recommendations on assessing and managing renal stones, see the NICE guideline on renal and ureteric stones)
  • an incidental finding of elevated albumin-adjusted serum calcium (2.6 mmol/litre or above).

1.1.2 Consider measuring albumin-adjusted serum calcium for people with chronic non-differentiated symptoms.

1.1.3 Do not measure ionised calcium when testing for primary hyperparathyroidism.

1.1.4 Repeat the albumin-adjusted serum calcium measurement at least once if the first measurement is either:

  • 2.6 mmol/litre or above or
  • 2.5 mmol/litre or above and features of primary hyperparathyroidism are present.

    Base the decision to carry out further repeat measurements on the level of albumin-adjusted serum calcium and the person’s symptoms.

Measuring parathyroid hormone

1.1.5 Measure parathyroid hormone (PTH) for people whose albumin-adjusted serum calcium level is either:

  • 2.6 mmol/litre or above on at least 2 separate occasions or
  • 2.5 mmol/litre or above on at least 2 separate occasions and primary hyperparathyroidism is suspected.

1.1.6 When measuring PTH, use a random sample and do a concurrent measurement of the albumin-adjusted serum calcium level.

1.1.7 Do not routinely repeat PTH measurement in primary care.

1.1.8 Seek advice from a specialist with expertise in primary hyperparathyroidism if the person’s PTH measurement is either:

  • above the midpoint of the reference range and primary hyperparathyroidism is suspected or
  • below the midpoint of the reference range with a concurrent albumin-adjusted serum calcium level of 2.6 mmol/litre or above.

1.1.9 Do not offer further investigations for primary hyperparathyroidism if:

  • the person’s PTH is within the reference range but below the midpoint of the reference range and
  • their concurrent albumin-adjusted serum calcium level is below 2.6 mmol/litre.

1.1.10 Look for alternative diagnoses, including malignancy, if the person’s PTH is below the lower limit of the reference range.

1.6 Monitoring

1.6.1 Offer monitoring to all people diagnosed with primary hyperparathyroidism, as set out in table 1.

Table 1: Monitoring for people with primary hyperparathyroidism
People who have had successful parathyroid surgery
People who have not had parathyroid surgery, or whose surgery has not been successful

Measure albumin-adjusted serum calcium once a year.

Measure albumin-adjusted serum calcium and eGFR or serum creatinine once a year, unless the person is taking cinacalcet*.

If the person is taking cinacalcet, offer monitoring as set out in the summary of product characteristics.

If the results of monitoring raise concerns, follow recommendation 1.1.4.

If the person has osteoporosis, seek specialist opinion according to local pathways on monitoring.

 

Consider a DXA scan at diagnosis and every 2 to 3 years.

If the results of monitoring raise concerns, follow recommendation 1.3.1.

 

If the person has renal stones, seek specialist opinion according to local pathways on monitoring.

Offer ultrasound of the renal tract at diagnosis, when presenting and if a renal stone is suspected (for recommendations on assessing and managing renal stones, see the NICE guideline on renal and ureteric stones).

If the results of monitoring raise concerns, follow recommendation 1.3.1.

For people who have had parathyroid surgery for multigland disease, or have disease that recurs after successful surgery, seek specialist endocrine opinion on monitoring.

For women who are pregnant, see the section on pregnancy in this summary.

For all people with primary hyperparathyroidism, assess cardiovascular risk and fracture risk in line with the NICE guidelines on cardiovascular disease and osteoporosis.

Abbreviations: DXA=dual-energy X‑ray absorptiometry; EGFR=estimated glomerular filtration rate.

* At the time of publication (May 2019), cinacalcet did not have a UK marketing authorisation for use after unsuccessful surgery for primary hyperparathyroidism. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Prescribing guidance: prescribing unlicensed medicines for further information.

 

1.7 Pregnancy

Care before pregnancy

1.7.1 Offer parathyroid surgery to women who have primary hyperparathyroidism and are considering pregnancy.

Care during pregnancy

1.7.2 Discuss the management of primary hyperparathyroidism for pregnant women with a multi-disciplinary team (MDT) in a specialist centre, and refer the woman for specialist care if needed. The MDT should include:

  • an obstetrician
  • a physician with expertise in primary hyperparathyroidism
  • a surgeon
  • a midwife
  • an anaesthetist.

1.7.3 Do not offer cinacalcet to pregnant women with primary hyperparathyroidism.

1.7.4 Do not offer a bisphosphonate to pregnant women with primary hyperparathyroidism.

1.7.5 Be aware that women with primary hyperparathyroidism are at increased risk of hypertensive disease in pregnancy. For recommendations on diagnosing and managing hypertension in pregnant women, see the NICE guideline on hypertension in pregnancy.

1.7.6 Consult a specialist centre MDT for advice on monitoring for pregnant women with primary hyperparathyroidism.

1.8 Information and support

1.8.1 Follow the recommendations on enabling people to actively participate in their care in the NICE guideline on patient experience in adult NHS services.

1.8.2 Give people with primary hyperparathyroidism information about the condition, including:

  • what primary hyperparathyroidism is
  • what the parathyroid glands do
  • causes of primary hyperparathyroidism
  • symptoms
  • diagnosis, including diagnosis if calcium or PTH levels are normal
  • prognosis
  • possible effects on daily life
  • possible long-term effects.

1.8.3 Give people information about treatments for primary hyperparathyroidism that includes:

  • the surgical and non-surgical treatments that are available
  • how well the treatments are likely to work
  • the advantages and disadvantages of each treatment, including possible complications and side effects
  • why these particular treatments are being offered
  • why other treatments are not advised.

1.8.4 Give advice on how to reduce the symptoms of primary hyperparathyroidism and prepare for surgery or other treatment, including:

  • exercise
  • diet
  • hydration
  • pain relief
  • what to expect after treatment, recovery time and return to daily activities, including return to work.

1.8.5 Discuss ongoing care and monitoring for primary hyperparathyroidism, explaining the type and frequency of monitoring that will be offered and the purpose of each. See section 1.6 for recommendations on monitoring.

© NICE 2019. Hyperparathyroidism (primary): diagnosis, assessment and initial management. Available from: www.nice.org.uk/guidance/ng132. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.

Published: May 2019