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Bhadada SK, Ghosh J, Pal R, Mukherjee S. Phosphate: An underrated component of primary hyperparathyroidism. Best Pract Res Clin Endocrinol Metab 2024; 38:101837. [PMID: 37926613 DOI: 10.1016/j.beem.2023.101837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
Primary hyperparathyroidism (PHPT) is a systemic disease that affects all the systems of the body, specifically the bones and the kidneys. Its main action is on calcium homeostasis. It tries to preserve the body's calcium level at the cost of phosphate. The criteria for surgery in asymptomatic PHPT patients revolve around raised serum calcium levels, renal dysfunction or nephrolithiasis, and bone health. It does not take into account the serum phosphate levels. Depending on the serum level, Hypophosphatemia is divided into mild, moderate, and severe categories. In PHPT, several studies have suggested that asymptomatic PHPT patients with moderate hypophosphatemia may warrant surgical intervention. Treatment of hypophosphatemia in PHPT is based upon the degree of hypophosphatemia, and treatment is given according to that oral or intravenous route; after surgical and medical treatment of PHPT, phosphate levels gradually normalized. But even after these considerations, phosphate levels in PHPT are not given much importance.
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Affiliation(s)
| | | | - Rimesh Pal
- Department of Endocrinology, PGIMER, Chandigarh, India.
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Abstract
Primary hyperparathyroidism (PHPT), the most common cause of hypercalcemia, is most often identified in postmenopausal women with hypercalcemia and parathyroid hormone (PTH) levels that are either frankly elevated or inappropriately normal. The clinical presentation of PHPT includes three phenotypes: target organ involvement of the renal and skeletal systems; mild asymptomatic hypercalcemia; and more recently, high PTH levels in the context of persistently normal albumin-corrected and ionized serum calcium values. The factors that determine which of these three clinical presentations is more likely to predominate in a given country include the extent to which biochemical screening is employed, the prevalence of vitamin D deficiency, and whether a medical center or practitioner tends to routinely measure PTH levels in the evaluation of low bone density or frank osteoporosis. When biochemical screening is common, asymptomatic primary hyperparathyroidism is the most likely form of the disease. In countries where vitamin D deficiency is prevalent and biochemical screening is not a feature of the health care system, symptomatic disease with skeletal abnormalities is likely to predominate. Finally, when PTH levels are part of the evaluation for low bone mass, the normocalcemic variant is seen. Guidelines for surgical removal of hyperfunctioning parathyroid tissue apply to all three clinical forms of the disease. If guidelines for surgery are not met, parathyroidectomy can also be an appropriate option if there are no medical contraindications to surgery. In settings where either the serum calcium or bone mineral density is of concern, and surgery is not an option, pharmacological approaches are available and effective. Referencing in this article the most current published articles, we review the different presentations of PHPT, with particular emphasis on recent advances in our understanding of target organ involvement and management.
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Affiliation(s)
- Barbara C Silva
- Division of Endocrinology, Felicio Rocho and Santa Casa Hospital, Belo Horizonte, Brazil
| | - Natalie E Cusano
- Division of Endocrinology, Lenox Hill Hospital, New York, NY, USA
| | - John P Bilezikian
- Division of Endocrinology, College of Physicians and Surgeons, Columbia University, New York, NY, USA.
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Rajput S, Dutta A, Rajender S, Mithal A, Chattopadhyay N. Efficacy of antiresorptive agents bisphosphonates and denosumab in mitigating hypercalcemia and bone loss in primary hyperparathyroidism: A systematic review and meta-analysis. Front Endocrinol (Lausanne) 2023; 14:1098841. [PMID: 36817591 PMCID: PMC9931892 DOI: 10.3389/fendo.2023.1098841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 01/04/2023] [Indexed: 02/05/2023] Open
Abstract
PURPOSE Primary hyperparathyroidism (PHPT) is characterized by increased bone remodeling and hypercalcemia. Parathyroidectomy (PTX), the current standard of care, is recommended in all symptomatic and some groups of asymptomatic patients. Anti-resorptive therapies (bisphosphonates and denosumab) have been used in patients where PTX is refused or contraindicated. In this meta-analysis, we investigated the effectiveness of anti-resorptives in preventing/treating PHPT-induced bone loss and mitigating hypercalcemia. METHOD PubMed, Scopus, and Cochrane Library databases were searched for articles with keywords containing PHPT, bisphosphonates, and denosumab in various combinations. We extracted and tabulated areal BMD (aBMD), serum mineral, and bone turnover parameters from the qualified studies and used comprehensive meta-analysis software for analysis. RESULTS Of the 1,914 articles screened, 13 were eligible for meta-analysis. In the pooled analysis, 12 months of anti-resoptives (bisphosphonates and denosumab) therapy significantly increased aBMD at the lumbar spine (Standard difference in means (SDM)=0.447, 95% CI=0.230 to 0.664, p=0.0001), femoral neck (SDM=0.270, 95% CI=0.049 to 0.491, p=0.017) and increased serum PTH (SDM=0.489, 95% CI=0.139 to 0.839, p=0.006), and decreased serum calcium (SDM=-0.545, 95% CI=-0.937 to -0.154, p=0.006) compared with baseline. 12 months of bisphosphonate use significantly increased aBMD only at the lumbar spine (SDM=0.330, 95% CI=0.088 to 0.571, p=0.007) with a significant increased in serum PTH levels (SDM=0.546, 95% CI= 0.162 to 0.930, p=0.005), and a decreased in serum calcium (SDM=-0.608, 95% CI=-1.048 to -0.169, p=0.007) and bone-turnover markers (BTMs) compared with baseline. Denosumab use for 12 months significantly increased aBMD at both the lumbar spine (SDM=0.828, 95% CI=0.378 to 1.278, p=0.0001) and femur neck (SDM=0.575, 95% CI=0.135 to 1.015, p=0.010) compared with baseline. Mean lumbar spine aBMD (SDM=0.350, 95% CI=0.041 to 0.659, p=0.027) and serum PTH (SDM=0.602, 95% CI= 0.145 to 1.059, p=0.010) were significantly increased after 12 months of alendronate use compared with placebo. When compared with baseline, alendronate significantly decreased BTMs after 12 months and increased aBMD without altering the PTH and calcium levels after 24 months. CONCLUSION Anti-resorptives are effective in mitigating bone loss and hypercalcemia in PHPT while maintaining or increasing aBMD. PTX reversed all changes in PHPT and normalized PTH levels.
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Affiliation(s)
- Swati Rajput
- Division of Endocrinology and Centre for Research in Anabolic Skeletal Targets in Health and Illness (ASTHI), CSIR-Central Drug Research Institute, Lucknow, India
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, India
| | - Aditya Dutta
- Institute of Endocrinology and Diabetes, Max Healthcare, Institutional Area, Press Enclave Road, Saket, New Delhi, India
| | - Singh Rajender
- Division of Endocrinology and Centre for Research in Anabolic Skeletal Targets in Health and Illness (ASTHI), CSIR-Central Drug Research Institute, Lucknow, India
| | - Ambrish Mithal
- Institute of Endocrinology and Diabetes, Max Healthcare, Institutional Area, Press Enclave Road, Saket, New Delhi, India
- *Correspondence: Ambrish Mithal, ; Naibedya Chattopadhyay,
| | - Naibedya Chattopadhyay
- Division of Endocrinology and Centre for Research in Anabolic Skeletal Targets in Health and Illness (ASTHI), CSIR-Central Drug Research Institute, Lucknow, India
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, India
- *Correspondence: Ambrish Mithal, ; Naibedya Chattopadhyay,
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Bandeira F, Nóbrega JDM, Oliveira LBD, Bilezikian J. Medical management of primary hyperparathyroidism. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2022; 66:689-693. [PMID: 36382758 PMCID: PMC10118813 DOI: 10.20945/2359-3997000000558] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Primary hyperparathyroidism (PHPT) is an endocrine disorder resulting from the hyperfunction of one or more parathyroid glands, with hypersecretion of parathyroid hormone (PTH). It can be managed by parathyroidectomy (PTX) or non-surgically. Medical therapy with pharmacological agents is an alternative for those patients with asymptomatic PHPT who meet guidelines for surgery but are unable or unwilling to undergo PTX. In this review, we focus upon these non-surgical aspects of PHPT management. We emphasize the most studied and widely used pharmacological alternatives: bisphosphonates, denosumab, cinacalcet and hormone therapy, in addition to combined therapy. We also address the relevant aspects of perioperative management.
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Bilezikian JP, Silverberg SJ, Bandeira F, Cetani F, Chandran M, Cusano NE, Ebeling PR, Formenti AM, Frost M, Gosnell J, Lewiecki EM, Singer FR, Gittoes N, Khan AA, Marcocci C, Rejnmark L, Ye Z, Guyatt G, Potts JT. Management of Primary Hyperparathyroidism. J Bone Miner Res 2022; 37:2391-2403. [PMID: 36054638 DOI: 10.1002/jbmr.4682] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 08/11/2022] [Accepted: 08/14/2022] [Indexed: 11/11/2022]
Abstract
Since the last international guidelines were published in 2014 on the evaluation and management of primary hyperparathyroidism (PHPT), new information has become available with regard to evaluation, diagnosis, epidemiology, genetics, classical and nonclassical manifestations, surgical and nonsurgical approaches, and natural history. To provide the most current summary of these developments, an international group, consisting of over 50 experts in these various aspects of PHPT, was convened. This paper provides the results of the task force that was assigned to review the information on the management of PHPT. For this task force on the management of PHPT, two questions were the subject of systematic reviews using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology. The full report addressing surgical and nonsurgical management of PHPT, utilizing the GRADE methodology, is published separately in this series. In this report, we summarize the results of that methodological review and expand them to encompass a much larger body of new knowledge that did not specifically fit the criteria of the GRADE methodology. Together, both the systematic and narrative reviews of the literature, summarized in this paper, give the most complete information available to date. A panel of experts then considered the last set of international guidelines in light of the newer data and assessed the need for their revision. This report provides the evidentiary background to the guidelines report. In that report, evidence from all task forces is synthesized into a summary statement and revised guidelines for the evaluation and management of PHPT. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- John P Bilezikian
- Division of Endocrinology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Shonni J Silverberg
- Division of Endocrinology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Francisco Bandeira
- Division of Endocrinology, University of Pernambuco Medical School Recife, Recife, Brazil
| | | | - Manju Chandran
- Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - Natalie E Cusano
- Division of Endocrinology, Department of Medicine, Lenox Hill Hospital, New York, NY, USA
| | - Peter R Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - Anna Maria Formenti
- Institute of Endocrine and Metabolic Sciences, San Raffaele Vita-Salute University and IRCCS Hospital, Milan, Italy
| | - Morten Frost
- Bone and Calcium Unit & Molecular Endocrinology Unit, Department of Endocrinology, Odense University Hospital, Odense, Denmark
| | - Jessica Gosnell
- Department of Surgery, University of California, San Francisco, CA, USA
| | - E Michael Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, Albuquerque, NM, USA
| | - Frederick R Singer
- Endocrine/Bone Disease Program, Saint John's Cancer Institute, Santa Monica, CA, USA
| | - Neil Gittoes
- Centre for Endocrinology, Diabetes and Metabolism, Queen Elizabeth Hospital and University of Birmingham, Birmingham, UK
| | - Aliya A Khan
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, ON, Canada
| | - Claudio Marcocci
- Department of Clinical and Experimental Medicine, University of Pisa, Endocrine Unit 2, University Hospital of Pisa, Pisa, Italy
| | - Lars Rejnmark
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Zhikang Ye
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - John T Potts
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Bilezikian JP, Khan AA, Silverberg SJ, Fuleihan GEH, Marcocci C, Minisola S, Perrier N, Sitges-Serra A, Thakker RV, Guyatt G, Mannstadt M, Potts JT, Clarke BL, Brandi ML, Balaya Z, Hofbauer L, Insogna K, Lacroix A, Liberman UA, Palermo A, Rizzoli R, Wermers R, Hannan FM, Pepe J, Cipriani C, Eastell R, Liu J, Mithal A, Moreira CA, Peacock M, Silva B, Walker M, Chakhtoura M, Schini M, Zein OE, Almquist M, Farias LCB, Duh Q, Lang BH, LiVolsi V, Swayk M, Vriens MR, Vu T, Yeh MW, Yeh R, Shariq O, Poch LL, Bandeira F, Cetani F, Chandran M, Cusano NE, Ebeling PR, Gosnell J, Lewiecki EM, Singer FR, Frost M, Formenti AM, Karonova T, Gittoes N, Rejnmark L. Evaluation and Management of Primary Hyperparathyroidism: Summary Statement and Guidelines from the Fifth International Workshop. J Bone Miner Res 2022; 37:2293-2314. [PMID: 36245251 DOI: 10.1002/jbmr.4677] [Citation(s) in RCA: 90] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 08/11/2022] [Accepted: 08/14/2022] [Indexed: 11/10/2022]
Abstract
The last international guidelines on the evaluation and management of primary hyperparathyroidism (PHPT) were published in 2014. Research since that time has led to new insights into epidemiology, pathophysiology, diagnosis, measurements, genetics, outcomes, presentations, new imaging modalities, target and other organ systems, pregnancy, evaluation, and management. Advances in all these areas are demonstrated by the reference list in which the majority of listings were published after the last set of guidelines. It was thus, timely to convene an international group of over 50 experts to review these advances in our knowledge. Four Task Forces considered: 1. Epidemiology, Pathophysiology, and Genetics; 2. Classical and Nonclassical Features; 3. Surgical Aspects; and 4. Management. For Task Force 4 on the Management of PHPT, Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) methodology addressed surgical management of asymptomatic PHPT and non-surgical medical management of PHPT. The findings of this systematic review that applied GRADE methods to randomized trials are published as part of this series. Task Force 4 also reviewed a much larger body of new knowledge from observations studies that did not specifically fit the criteria of GRADE methodology. The full reports of these 4 Task Forces immediately follow this summary statement. Distilling the essence of all deliberations of all Task Force reports and Methodological reviews, we offer, in this summary statement, evidence-based recommendations and guidelines for the evaluation and management of PHPT. Different from the conclusions of the last workshop, these deliberations have led to revisions of renal guidelines and more evidence for the other recommendations. The accompanying papers present an in-depth discussion of topics summarized in this report. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- John P Bilezikian
- Division of Endocrinology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Aliya A Khan
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, ON, Canada
| | - Shonni J Silverberg
- Division of Endocrinology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Ghada El-Hajj Fuleihan
- Calcium Metabolism and Osteoporosis Program, WHO CC for Metabolic Bone Disorders, Division of Endocrinology, American University of Beirut, Beirut, Lebanon
| | - Claudio Marcocci
- Department of Clinical and Experimental Medicine, University of Pisa, Endocrine Unit 2, University Hospital of Pisa, Pisa, Italy
| | - Salvatore Minisola
- Department of Clinical, Internal, Anaesthesiologic and Cardiovascular Sciences, 'Sapienza', Rome University, Rome, Italy
| | - Nancy Perrier
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Rajesh V Thakker
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford Centre for Diabetes, Endocrinology and Metabolism (OCDEM), Churchill Hospital, Oxford, UK
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Michael Mannstadt
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - John T Potts
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Bart L Clarke
- Mayo Clinic Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Maria Luisa Brandi
- Fondazione Italiana sulla Ricerca sulle Malattie dell'Osso (F.I.R.M.O. Foundation), Florence, Italy
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Silva BC, Bilezikian JP. Skeletal abnormalities in Hypoparathyroidism and in Primary Hyperparathyroidism. Rev Endocr Metab Disord 2021; 22:789-802. [PMID: 33200346 DOI: 10.1007/s11154-020-09614-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/11/2020] [Indexed: 12/22/2022]
Abstract
Both hypoparathyroidism (HypoPT), as well as its pathological counterpart, primary hyperparathyroidism (PHPT), can lead to skeletal abnormalities. Chronic deficiency of PTH in patients with HypoPT is associated with a profound reduction in bone remodeling, with consequent increases in bone density, and abnormalities in microarchitecture and bone strength. It is still not clear whether there is an increase in fracture risk in HypoPT. While standard therapy with calcium supplements and active vitamin D does not restore bone homeostasis, treatment of HypoPT with PTH appears to correct some of those abnormalities. In PHPT, the continuous exposure to high levels of PTH causes an increase in bone remodeling, in which bone resorption prevails. In the symptomatic form of PHPT, patients can present with fragility fractures, and/or the classical radiological features of osteitis fibrosa cystica. However, even in mild PHPT, catabolic skeletal actions of PTH are evident through reduced BMD, deterioration of bone microarchitecture and increased risk of fragility fractures. Successful parathyroidectomy improves skeletal abnormalities. Medical treatment, such as bisphosphonates and denosumab, can also increase bone density in patients with PHPT who do not undergo surgery. This article reviews skeletal involvement in HypoPT and in PHPT, as assessed by bone remodeling, DXA, trabecular bone score, and quantitative computed tomography, as well as data on bone strength and fracture risk. The effects of PTH replacement on the skeleton in subjects with HypoPT, and the outcome of parathyroidectomy in patients with PHPT, are also reviewed here.
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Affiliation(s)
- Barbara C Silva
- Department of Medicine, Centro Universitario de Belo Horizonte - UNI BH, Belo Horizonte, Brazil
- Endocrinology Unit, Felicio Rocho Hospital, Belo Horizonte, Brazil
- Endocrinology Unit, Santa Casa Hospital, Belo Horizonte, Brazil
| | - John P Bilezikian
- Metabolic Bone Diseases Unit, Division of Endocrinology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, 630 W. 168th Street, PH 8E: 105G, New York, NY, 10032, USA.
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Santos LMD, Ohe MN, Pallone SG, Nacaguma IO, Kunii IS, da Silva REC, Vieira JGH, Lazaretti-Castro M. Trabecular Bone Score (TBS) in Primary Hyperparathyroidism (PHPT): A Useful Tool? J Clin Densitom 2021; 24:563-570. [PMID: 34045135 DOI: 10.1016/j.jocd.2021.04.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 01/31/2021] [Accepted: 04/06/2021] [Indexed: 10/21/2022]
Abstract
Primary Hyperparathyroidism (PHPT) often leads to bone loss, even in its asymptomatic presentations. Trabecular Bone Score (TBS) is a method to assess the trabecular bone structure of the spine. This study aimed to evaluate TBS measurements combined with Dual X-ray Absorptiometry (DXA) values in the search for more accurate bone fragility risk assessment among PHPT patients. From 2017 to 2019, patients diagnosed with PHPT (n = 64), before surgery, were invited to participate in this study. Bone mineral density (BMD) by DXA at the lumbar spine, total hip, femoral neck, distal third radius, and TBS were determined in patients and controls (n = 63). The vertebral fracture was defined using the Genant method in vertebral images by DXA and vertebral fracture assessment (VFA). Patients and controls did not differ in age, sex, menopausal status, or body mass index (BMI). The PHPT patients presented significantly lower BMD values than the controls in all sites evaluated. The TBS measurements were also statistically lower in PHPT patients than controls (mean TBS PHPT = 1.233 vs TBS controls = 1.280, p = 0.044). Osteoporosis was observed in 50% of PHPT patients and 26.6% of controls (p = 0.02). However, lumbar spine T-Score < -2.5 was observed only in 21.8% of PHPT patients. Vertebral fractures were detected in nine individuals (14%) from the PHPT group and four (6.3%) in the controls (p = 0.24). The TBS area under the curve (AUC) was higher than DXA AUC in all sites, for vertebral fracture assessment. The TBS AUC was significant in the PHPT group (0.75, 95% CI 0.62 - 0.88, p = 0.02) and not significant in the DXA analysis. The ROC curve showed that TBS values < 1.187 are associated with a significantly higher risk of vertebral fracture among PHPT patients (p = 0.02). The TBS used as a complement to DXA measurements is a useful tool which may better assess fragility risk among PHPT patients.
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Affiliation(s)
- Lívia Marcela Dos Santos
- Department of Medicine, Endocrinology Unit, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil.
| | - Monique Nakayama Ohe
- Department of Medicine, Endocrinology Unit, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Sthefanie Giovanna Pallone
- Department of Medicine, Endocrinology Unit, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Isabela Ohki Nacaguma
- Department of Medicine, Endocrinology Unit, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Ilda Sizue Kunii
- Department of Medicine, Endocrinology Unit, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Renata Elen Costa da Silva
- Department of Medicine, Endocrinology Unit, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | | | - Marise Lazaretti-Castro
- Department of Medicine, Endocrinology Unit, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
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Anagnostis P, Vaitsi K, Veneti S, Potoupni V, Kenanidis E, Tsiridis E, Papavramidis TS, Goulis DG. Efficacy of parathyroidectomy compared with active surveillance in patients with mild asymptomatic primary hyperparathyroidism: a systematic review and meta-analysis of randomized-controlled studies. J Endocrinol Invest 2021; 44:1127-1137. [PMID: 33074457 DOI: 10.1007/s40618-020-01447-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 10/07/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Parathyroidectomy (PTx) has an established benefit in patients with symptomatic primary hyperparathyroidism (PHPT). However, its efficacy in mild asymptomatic PHPT has not been proven. This study aimed to systematically review and meta-analyze the best available evidence from randomized-controlled trials comparing the efficacy of PTx over conservative management (non-PTx) on skeletal outcomes [fractures and bone mineral density (BMD)], nephrolithiasis risk and quality of life (QoL) in patients with mild asymptomatic PHPT. METHODS A comprehensive literature search was conducted in PubMed, Scopus and Cochrane databases, from conception to February 23, 2020. Data were extracted from the studies that fulfilled the eligibility criteria and were synthesized quantitatively (fixed or random effects model) as relative risks and percentage mean differences (MD) with 95% confidence intervals (CI). I2 index was employed for heterogeneity. RESULTS Four studies were included in the meta-analysis. There was no difference in fracture risk between PTx and active surveillance. The PTx group demonstrated higher BMD [MD 3.55% (95% CI 1.81, 5.29) in lumbar spine and 3.44% (95% CI 1.39, 5.49) in total hip, without difference in femoral neck and forearm] and lower calcium concentrations (MD - 13.26%, 95% CI - 7.10, - 19.43) compared with the non-PTx group. No difference was observed between groups regarding nephrolithiasis or QoL indices, except for general health (higher in PTx group). CONCLUSIONS In patients with mild asymptomatic PHPT, PTx increases BMD and reduces serum calcium concentrations. However, its superiority over active surveillance in terms of fracture risk, nephrolithiasis and QoL cannot be supported by current data.
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Affiliation(s)
- P Anagnostis
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece.
- Centre of Orthopedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece.
- Academic Orthopedic Unit, Aristotle University Medical School, General Hospital Papageorgiou, Thessaloniki, Greece.
| | - K Vaitsi
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Centre of Orthopedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - S Veneti
- 1st Propedeutic Department of Surgery, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - V Potoupni
- Centre of Orthopedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece
- Academic Orthopedic Unit, Aristotle University Medical School, General Hospital Papageorgiou, Thessaloniki, Greece
| | - E Kenanidis
- Centre of Orthopedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece
- Academic Orthopedic Unit, Aristotle University Medical School, General Hospital Papageorgiou, Thessaloniki, Greece
| | - E Tsiridis
- Centre of Orthopedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece
- Academic Orthopedic Unit, Aristotle University Medical School, General Hospital Papageorgiou, Thessaloniki, Greece
| | - T S Papavramidis
- 1st Propedeutic Department of Surgery, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - D G Goulis
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Centre of Orthopedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece
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10
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Dandurand K, Ali DS, Khan AA. Primary Hyperparathyroidism: A Narrative Review of Diagnosis and Medical Management. J Clin Med 2021; 10:jcm10081604. [PMID: 33918966 PMCID: PMC8068862 DOI: 10.3390/jcm10081604] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/26/2021] [Accepted: 04/06/2021] [Indexed: 12/13/2022] Open
Abstract
Primary hyperparathyroidism (PHPT) is the most common cause of hypercalcemia in the outpatient setting. Symptomatic presentation includes non-specific signs and symptoms of hypercalcemia, skeletal fragility, nephrolithiasis and nephrocalcinosis. The majority of individuals present at an asymptomatic stage following routine biochemical screening, without any signs or symptoms of calcium or parathyroid hormone (PTH) excess or target organ damage. Indications for surgery have recently been revised as published in recent guidelines and consensus statements. Parathyroidectomy is advised in patients younger than 50 years old and in the presence of either significant hypercalcemia, impaired renal function, renal stones or osteoporosis. Surgery is always appropriate in suitable surgical candidates, however, medical management may be considered in those with mild asymptomatic disease, contraindications to surgery or failed previous surgical intervention. We summarized the optimal medical interventions available in the care of PHPT patients not undergoing parathyroidectomy. Calcium and vitamin D intake should be optimized. Antiresorptive therapy may be used for skeletal protection in patients with an increased fracture risk. Cinacalcet, a calcimimetic agent, has been shown to effectively lower serum calcium and PTH levels. The effect of medical treatment on the reduction in fracture risk is unknown and should be the focus of future research.
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11
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Alfadhli EM. Management of Primary Hyperparathyroidism With Severe Hypercalcemia During the COVID-19 Pandemic. Clin Ther 2021; 43:711-719. [PMID: 33752899 PMCID: PMC7976275 DOI: 10.1016/j.clinthera.2021.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 01/01/2021] [Accepted: 02/18/2021] [Indexed: 01/07/2023]
Abstract
Purpose In patients with primary hyperparathyroidism (PHPT) and severe hypercalcemia, parathyroidectomy remains the only curative therapy. During the coronavirus disease 2019 (COVID-19) pandemic, when many hospital visits are suspended and surgeries cannot be performed, the management of these patients represents a challenging clinical situation. This article presents a literature review and discussion of the pharmacologic management of PHPT and severe hypercalcemia, which can be used as a temporary measure during the COVID-19 pandemic until parathyroidectomy can be performed safely. Methods This narrative review was conducted by searching literature on the PubMed, Medline, and Google Scholar databases using the terms primary hyperparathyroidism, hypercalcemia, cinacalcet, bisphosphonates, denosumab, vitamin D, raloxifene, hormone replacement therapy, coronavirus, and COVID-19. Findings Appropriate monitoring and remote medical follow-up of these patients are essential until the resolution of the pandemic. Cinacalcet is the drug of choice for controlling hypercalcemia, whereas bisphosphonate or denosumab is the drug for improving bone mineral density. Combined therapy with cinacalcet and bisphosphonates or cinacalcet and denosumab should be considered when the effects on serum calcium and bone mineral density are simultaneously desired. Implications Medical management of PHPT and severe hypercalcemia presents a reasonable alternative for parathyroid surgery during the COVID-19 outbreak and should be instituted until the pandemic ends and surgery can be performed safely.
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Affiliation(s)
- Eman M Alfadhli
- Department of Medicine, Medical College, Taibah University, Medina, Saudi Arabia.
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12
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Ganesan C, Weia B, Thomas IC, Song S, Velaer K, Seib CD, Conti S, Elliott C, Chertow GM, Kurella Tamura M, Leppert JT, Pao AC. Analysis of Primary Hyperparathyroidism Screening Among US Veterans With Kidney Stones. JAMA Surg 2021; 155:861-868. [PMID: 32725208 DOI: 10.1001/jamasurg.2020.2423] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Importance Approximately 3% to 5% of patients with kidney stones have primary hyperparathyroidism (PHPT), a treatable cause of recurrent stones. However, the rate of screening for PHPT in patients with kidney stones remains unknown. Objectives To estimate the prevalence of parathyroid hormone (PTH) testing in veterans with kidney stones and hypercalcemia and to identify the demographic, geographic, and clinical characteristics of veterans who were more or less likely to receive PTH testing. Design, Setting, and Participants This cohort study obtained Veterans Health Administration (VHA) health records from the Corporate Data Warehouse for veterans who received care in 1 of the 130 VHA facilities across the United States from January 1, 2008, through December 31, 2013. Historical encounters, medical codes, and laboratory data were assessed. Included patients had diagnostic or procedural codes for kidney or ureteral stones, and excluded patients were those with a previous serum PTH level measurement. Data were collected from January 1, 2006, to December 31, 2014. Data analysis was conducted from June 1, 2019, to January 31, 2020. Exposures Elevated serum calcium concentration measurement between 6 months before and 6 months after kidney stone diagnosis. Main Outcomes and Measures Proportion of patients with a serum PTH level measurement and proportion of patients with biochemical evidence of PHPT who underwent parathyroidectomy. Results The final cohort comprised 7561 patients with kidney stones and hypercalcemia and a mean (SD) age of 64.3 (12.3) years. Of these patients, 7139 were men (94.4%) and 5673 were white individuals (75.0%). The proportion of patients who completed a serum PTH level measurement was 24.8% (1873 of 7561). Across the 130 VHA facilities included in the study, testing rates ranged from 4% to 57%. The factors associated with PTH testing included the magnitude of calcium concentration elevation (odds ratio [OR], 1.07 per 0.1 mg/dL >10.5 mg/dL; 95% CI, 1.05-1.08) and the number of elevated serum calcium concentration measurements (OR, 1.08 per measurement >10.5 mg/dL; 95% CI, 1.06-1.10) as well as visits to both a nephrologist and a urologist (OR, 6.57; 95% CI, 5.33-8.10) or an endocrinologist (OR, 4.93; 95% CI, 4.11-5.93). Of the 717 patients with biochemical evidence of PHPT, 189 (26.4%) underwent parathyroidectomy within 2 years of a stone diagnosis. Conclusions and Relevance This cohort study found that only 1 in 4 patients with kidney stones and hypercalcemia were tested for PHPT in VHA facilities and that testing rates varied widely across these facilities. These findings suggest that raising clinician awareness to PHPT screening indications may improve evaluation for parathyroidectomy, increase the rates of detection and treatment of PHPT, and decrease recurrent kidney stone disease.
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Affiliation(s)
- Calyani Ganesan
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Benjamin Weia
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - I-Chun Thomas
- Division of Nephrology, Department of Urology, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Shen Song
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Kyla Velaer
- Department of Urology, Stanford University School of Medicine, Palo Alto, California
| | - Carolyn D Seib
- Department of Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Simon Conti
- Department of Urology, Stanford University School of Medicine, Palo Alto, California
| | - Chris Elliott
- Department of Urology, Santa Clara Valley Medical Center, San Jose, California
| | - Glenn M Chertow
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California.,Department of Epidemiology and Population Health, Stanford University School of Medicine, Palo Alto, California
| | - Manjula Kurella Tamura
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California.,Division of Nephrology, Department of Urology, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - John T Leppert
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California.,Division of Nephrology, Department of Urology, Veterans Affairs Palo Alto Health Care System, Palo Alto, California.,Department of Urology, Stanford University School of Medicine, Palo Alto, California
| | - Alan C Pao
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California.,Division of Nephrology, Department of Urology, Veterans Affairs Palo Alto Health Care System, Palo Alto, California.,Department of Urology, Stanford University School of Medicine, Palo Alto, California
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13
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Cipriani C, Bilezikian JP. Non-surgical management of primary hyperparathyroidism in the aging population. Maturitas 2020; 136:49-53. [PMID: 32386666 DOI: 10.1016/j.maturitas.2020.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 04/02/2020] [Accepted: 04/08/2020] [Indexed: 01/24/2023]
Abstract
Primary hyperparathyroidism (PHPT) is commonly observed in the aging population, and the average age at diagnosis has increased in the last 20 years. Parathyroidectomy, the only definitive cure for PHPT, is indicated in symptomatic and asymptomatic older PHPT patients with skeletal and renal disease. It is as effective in older patients as it is in younger patients. Nevertheless, older patients may present with comorbidities and greater frailty, leading to the possibility of more complications, higher morbidity and mortality after surgery. This review focuses on the non-surgical clinical management of PHPT in elderly patients. We also summarize the most recent literature regarding the pharmacological management of PHPT to reduce serum calcium levels, to improve bone mineral density or to do both in the aging population.
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Affiliation(s)
- Cristiana Cipriani
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.
| | - John P Bilezikian
- Division of Endocrinology, Columbia University College of Physicians and Surgeons, 630 W 168th St, New York, NY 10032, USA.
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14
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Abstract
BACKGROUND Primary hyperparathyroidism (PHPT), the most common cause of hypercalcemia, is most often identified in postmenopausal women. The clinical presentation of PHPT has evolved over the past 40 years to include three distinct clinical phenotypes, each of which has been studied in detail and has led to evolving concepts about target organ involvement, natural history, and management. METHODS In the present review, I provide an evidence-based summary of this disorder as it has been studied worldwide, citing key concepts and data that have helped to shape our concepts about this disease. RESULTS PHPT is now recognized to include three clinical phenotypes: overt target organ involvement, mild asymptomatic hypercalcemia, and high PTH levels with persistently normal albumin-corrected and ionized serum calcium values. The factors that determine which of these clinical presentations is more likely to predominate in a given country include the extent to which biochemical screening is used, vitamin D deficiency is present, and whether parathyroid hormone levels are routinely measured in the evaluation of low bone density or frank osteoporosis. Guidelines for parathyroidectomy apply to all three clinical forms of the disease. If surgical guidelines are not met, parathyroidectomy can also be an appropriate option if no medical contraindications are present. If either the serum calcium or bone mineral density is of concern and surgery is not an option, pharmacological approaches are available and effective. CONCLUSIONS Advances in our knowledge of PHPT have guided new concepts in diagnosis and management.
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Affiliation(s)
- John P Bilezikian
- Division of Endocrinology, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York
- Correspondence and Reprint Requests: John P. Bilezikian, MD, Department of Medicine, College of Physicians and Surgeons, University of Columbia, 630 West 168th Street, New York, New York 10032. E-mail:
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15
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Abstract
Primary hyperparathyroidism (PHPT), the most common cause of hypercalcemia, is most often identified in postmenopausal women with hypercalcemia and parathyroid hormone (PTH) levels that are either frankly elevated or inappropriately normal. The clinical presentation of PHPT includes three phenotypes: target organ involvement of the renal and skeletal systems; mild asymptomatic hypercalcemia; and more recently, high PTH levels in the context of persistently normal albumin-corrected and ionized serum calcium values. The factors that determine which of these three clinical presentations is more likely to predominate in a given country include the extent to which biochemical screening is employed, the prevalence of vitamin D deficiency, and whether a medical center or practitioner tends to routinely measure PTH levels in the evaluation of low bone density or frank osteoporosis. When biochemical screening is common, asymptomatic primary hyperparathyroidism is the most likely form of the disease. In countries where vitamin D deficiency is prevalent and biochemical screening is not a feature of the health care system, symptomatic disease with skeletal abnormalities is likely to predominate. Finally, when PTH levels are part of the evaluation for low bone mass, the normocalcemic variant is seen. Guidelines for surgical removal of hyperfunctioning parathyroid tissue apply to all three clinical forms of the disease. If guidelines for surgery are not met, parathyroidectomy can also be an appropriate option if there are no medical contraindications to surgery. In settings where either the serum calcium or bone mineral density is of concern, and surgery is not an option, pharmacological approaches are available and effective. Referencing in this article the most current published articles, we review the different presentations of PHPT, with particular emphasis on recent advances in our understanding of target organ involvement and management.
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Affiliation(s)
- Barbara C Silva
- Division of Endocrinology, Felicio Rocho and Santa Casa Hospital, Belo Horizonte, Brazil; Department of Medicine, Centro Universitario de Belo Horizonte (UNIBH), Brazil
| | - Natalie E Cusano
- Division of Endocrinology, Lenox Hill Hospital, New York, NY, USA
| | - John P Bilezikian
- Division of Endocrinology, College of Physicians and Surgeons, Columbia University, New York, NY, USA.
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16
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Makras P, Anastasilakis AD. Bone disease in primary hyperparathyroidism. Metabolism 2018; 80:57-65. [PMID: 29051042 DOI: 10.1016/j.metabol.2017.10.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 10/05/2017] [Accepted: 10/07/2017] [Indexed: 11/16/2022]
Abstract
Primary hyperparathyroidism (PHPT) is a disease of high bone turnover, decreased bone mineral density (BMD) especially at cortical sites, and increased risk of fractures at all skeletal sites. Early diagnosis during the last decades resulted in milder forms of bone involvement. New methods of imaging and validation such as high resolution peripheral quantitative computed tomography and trabecular bone score provide evidence of disturbed bone microarchitecture and explain further the increased risk of fractures at both cortical and trabecular skeletal sites. Parathyroidectomy has a long-term beneficial effect on the skeleton and is probably prudent to refer PHPT patients for surgery in all cases where increased bone fragility is suspected. Bisphosphonates (BPs), mainly alendronate, have been proved as reasonable choices for BMD improvement while cinacalcet has no effect on bone strength in PHPT. Combination of BPs and cinacalcet, is a valid therapeutic approach from a pathophysiological point of view at least in terms of bone health, however, an adequately powered study to prove it is lacking. Adequate dietary calcium intake and vitamin D supplementation is advised as in the general population for the skeletal integrity of PHPT patients albeit with a close monitoring of serum and urinary calcium levels.
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Affiliation(s)
- Polyzois Makras
- Department of Endocrinology and Diabetes, 251 Hellenic Air Force & VA General Hospital, Athens, Greece
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17
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Abstract
In this Review, we describe the pathogenesis, diagnosis and management of primary hyperparathyroidism (PHPT), with a focus on recent advances in the field. PHPT is a common endocrine disorder that is characterized by hypercalcaemia and elevated or inappropriately normal serum levels of parathyroid hormone. Most often, the presentation of PHPT is asymptomatic in regions of the world where serum levels of calcium are routinely measured. In addition to mild hypercalcaemia, PHPT can manifest with osteoporosis and hypercalciuria as well as with vertebral fractures and nephrolithiasis, both of which can be asymptomatic. Other clinical forms of PHPT, such as classical disease and normocalcaemic PHPT, are less common. Parathyroidectomy, the only curative treatment for PHPT, is recommended in patients with symptoms and those with asymptomatic disease who are at risk of progression or have subclinical evidence of end-organ sequelae. Parathyroidectomy results in an increase in BMD and a reduction in nephrolithiasis. Various medical therapies can increase BMD or reduce serum levels of calcium, but no single drug can do both. More data are needed regarding the neuropsychological manifestations of PHPT and the pathogenetic mechanisms leading to sporadic PHPT, as well as on risk factors for complications of the disorder. Future work that advances our knowledge in these areas will improve the management of the disorder.
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Affiliation(s)
- Marcella D Walker
- Division of Endocrinology, Department of Medicine, Columbia University, College of Physicians and Surgeons, New York, New York 10032, USA
| | - Shonni J Silverberg
- Division of Endocrinology, Department of Medicine, Columbia University, College of Physicians and Surgeons, New York, New York 10032, USA
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18
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Catabolic Effects of Human PTH (1-34) on Bone: Requirement of Monocyte Chemoattractant Protein-1 in Murine Model of Hyperparathyroidism. Sci Rep 2017; 7:15300. [PMID: 29127344 PMCID: PMC5681546 DOI: 10.1038/s41598-017-15563-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 10/30/2017] [Indexed: 01/12/2023] Open
Abstract
The bone catabolic actions of parathyroid hormone (PTH) are seen in patients with hyperparathyroidism, or with infusion of PTH in rodents. We have previously shown that the chemokine, monocyte chemoattractant protein-1 (MCP-1), is a mediator of PTH’s anabolic effects on bone. To determine its role in PTH’s catabolic effects, we continuously infused female wild-type (WT) and MCP-1−/− mice with hPTH or vehicle. Microcomputed tomography (µCT) analysis of cortical bone showed that hPTH-infusion induced significant bone loss in WT mice. Further, μCT analysis of trabecular bone revealed that, compared with the vehicle-treated group, the PTH-treated WT mice had reduced trabecular thickness and trabecular number. Notably, MCP-1−/− mice were protected against PTH-induced cortical and trabecular bone loss as well as from increases in serum CTX (C-terminal crosslinking telopeptide of type I collagen) and TRACP-5b (tartrate-resistant acid phosphatase 5b). In vitro, bone marrow macrophages (BMMs) from MCP-1−/− and WT mice were cultured with M-CSF, RANKL and/or MCP-1. BMMs from MCP-1−/− mice showed decreased multinucleated osteoclast formation compared with WT mice. Taken together, our work demonstrates that MCP-1 has a role in PTH’s catabolic effects on bone including monocyte and macrophage recruitment, osteoclast formation, bone resorption, and cortical and trabecular bone loss.
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19
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Leere JS, Karmisholt J, Robaczyk M, Vestergaard P. Contemporary Medical Management of Primary Hyperparathyroidism: A Systematic Review. Front Endocrinol (Lausanne) 2017; 8:79. [PMID: 28473803 PMCID: PMC5397399 DOI: 10.3389/fendo.2017.00079] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Accepted: 03/30/2017] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Primary hyperparathyroidism is increasingly an asymptomatic disease at diagnosis, but the recognized guidelines for management are based on evidence obtained from studies on patients with symptomatic disease, and surgery is not always indicated. Other patients are unable to undergo surgery, and thus a medical treatment is warranted. This systematic review provides an overview of the existing literature on contemporary pharmaceutical options available for the medical management of primary hyperparathyroidism. METHODS Databases of medical literature were searched for articles including terms for primary hyperparathyroidism and each of the included drugs. Data on s-calcium, s-parathyroid hormone, bone turnover markers, bone mineral density (BMD) and hard endpoints were extracted and tabulated, and level of evidence was determined. Changes in s-calcium were estimated and a meta-regression analysis was performed. RESULTS The 1,999 articles were screened for eligibility and 54 were included in the review. Weighted mean changes calculated for each drug in s-total calcium (mean change from baseline ± SEM) were pamidronate (0.31 ± 0.034 mmol/l); alendronate (0.07 ± 0.05 mmol/l); clodronate (0.20 ± 0.040 mmol/l); mixed bisphosphonates (0.16 ± 0.049 mmol/l); and cinacalcet (0.37 ± 0.013 mmol/l). The meta-analysis revealed a significant decrease of effect on s-calcium with time for the bisphosphonates (Coef. -0.049 ± 0.023, p = 0.035), while cinacalcet proved to maintain its effect on s-calcium over time. Bisphosphonates improved BMD while cinacalcet had no effect. DISCUSSION The included studies demonstrate advantages and drawbacks of the available pharmaceutical options that can prove helpful in the clinical setting. The great variation in how primary hyperparathyroidism is manifested requires that management should rely on an individual evaluation when counseling patients. Combining resorptive agents with calcimimetics could prove rewarding, but more studies are warranted.
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Affiliation(s)
- Julius Simoni Leere
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- *Correspondence: Julius Simoni Leere,
| | | | - Maciej Robaczyk
- Department of Endocrinology, Aalborg University, Aalborg, Denmark
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Mendonça ML, Batista SL, Nogueira-Barbosa MH, Salmon CEG, Paula FJAD. Primary Hyperparathyroidism: The Influence of Bone Marrow Adipose Tissue on Bone Loss and of Osteocalcin on Insulin Resistance. Clinics (Sao Paulo) 2016; 71:464-9. [PMID: 27626477 PMCID: PMC4975789 DOI: 10.6061/clinics/2016(08)09] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 04/29/2016] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Bone marrow adipose tissue has been associated with low bone mineral density. However, no data exist regarding marrow adipose tissue in primary hyperparathyroidism, a disorder associated with bone loss in conditions of high bone turnover. The objective of the present study was to investigate the relationship between marrow adipose tissue, bone mass and parathyroid hormone. The influence of osteocalcin on the homeostasis model assessment of insulin resistance was also evaluated. METHODS This was a cross-sectional study conducted at a university hospital, involving 18 patients with primary hyperparathyroidism (PHPT) and 21 controls (CG). Bone mass was assessed by dual-energy x-ray absorptiometry and marrow adipose tissue was assessed by 1H magnetic resonance spectroscopy. The biochemical evaluation included the determination of parathyroid hormone, osteocalcin, glucose and insulin levels. RESULTS A negative association was found between the bone mass at the 1/3 radius and parathyroid hormone levels (r = -0.69; p<0.01). Marrow adipose tissue was not significantly increased in patients (CG = 32.8±11.2% vs PHPT = 38.6±12%). The serum levels of osteocalcin were higher in patients (CG = 8.6±3.6 ng/mL vs PHPT = 36.5±38.4 ng/mL; p<0.005), but no associations were observed between osteocalcin and insulin or between insulin and both marrow adipose tissue and bone mass. CONCLUSION These results suggest that the increment of adipogenesis in the bone marrow microenvironment under conditions of high bone turnover due to primary hyperparathyroidism is limited. Despite the increased serum levels of osteocalcin due to primary hyperparathyroidism, these patients tend to have impaired insulin sensitivity.
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Affiliation(s)
- Maira L Mendonça
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Medicina Interna, Ribeirao Preto/SP, Brazil
| | - Sérgio L Batista
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Medicina Interna, Ribeirao Preto/SP, Brazil
| | - Marcello H Nogueira-Barbosa
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Medicina Interna, Ribeirao Preto/SP, Brazil
| | - Carlos E G Salmon
- Universidade de São Paulo, Faculdade de Filosofia, Ciências e Letras de Ribeirão Preto, Departamento de Física, Ribeirão Preto/SP, Brazil
| | - Francisco J A de Paula
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Medicina Interna, Ribeirao Preto/SP, Brazil
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Abstract
Over the past several generations, primary hyperparathyroidism (PHTP) has undergone a change in its clinical presentation in many countries from a symptomatic disease to an asymptomatic one. The reasons for this change in clinical presentation are related to the widespread use of biochemical screening tests, to the measurement of PTH more routinely in the evaluation of metabolic bone disease and to the status of vitamin D sufficiency in the population. Along with recognition of a broader clinical spectrum of disease, including a more recently recognized normocalcemic variant, has come an appreciation that the evaluation of classic target organs that can be affected in PHPT, such as the skeleton and the kidneys, require more advanced imaging technology for complete evaluation. It is clear that even in asymptomatic patients, evidence for microstructural disease in the skeleton and calcifications in the kidneys can be demonstrated often. Potential non-classical manifestations of PHPT related to neurocognition and the cardiovascular system continue to be of interest. As a result of these advances, revised guidelines for the management of asymptomatic PHPT have been recently published to help the clinician determine whether surgery is appropriate or whether a more conservative approach is acceptable.
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Affiliation(s)
- Leonardo Bandeira
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - John Bilezikian
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY, USA
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