Bisphosphonate Therapy in Primary Hyperparathyroidism

Abstract

We appreciate the comments of Hershman et al. regarding the potential use of the bisphosphonate alendronate in the medical management of patients with asymptomatic primary hyperparathyroidism who are not candidates for surgery. Patients who are or are not candidates for parathyroid surgery were redefined recently by the Panel that was convened after the National Institute of Health Workshop on Asymptomatic Primary Hyperparathyroidism.(1) Hershman et al. take issue with the Panel's statement that, because of "limited data," bisphosphonate therapy cannot be recommended as a medical approach. A major responsibility of the Panel that we cochaired was to be appropriately conservative about medical evidence that affects treatment guidelines. Hence, despite the promising potential of bisphosphonate therapy in the disease, particularly with respect to both rationale for and early results of changes in bone mineral density (BMD), no formal recommendation was made (nor on any other medical therapy).Three of the five references on bisphosphonate use in primary hyperparathyroidism to which Hershman et al. refer were published after the Conference and thus were not available to the Panel. At the time of the Conference, only two published reports they cite were available. Neither one was a randomized placebo-controlled double-blind study.(2,3) Since the Workshop, the published literature still contains only one randomized double-blinded placebocontrolled trial (4) ; another is available in abstract form.Another recently published study lacked a placebocontrolled group.(6) The two best-designed studies agree with the others that alendronate is associated with an increase in lumbar spine BMD within 1 year of therapy. Alendronate does not seem to alter significantly the serum calcium or parathyroid hormone concentration. Because these latter hallmarks of the disease are apparently not affected by the bisphosphonate, for those in whom the primary objective of medical therapy is to reduce circulating calcium and parathyroid hormone (PTH) levels, the calcimimetic agent, cinacalcet, would seem to have promise. Additional well-designed clinical trials are needed with alendronate and the other potential medical approaches to primary hyperparathyroidism demonstrating long-term safe and effective applicability before any definitive conclusion can be reached.

Hypoparathyroidism: Early Detection and Diagnosis Approaches

“…Dalam pengaturan pasca operasi, presentasi dapat menjadi akut dengan tetani, kram, takikardia, dan perubahan status mental yang mendominasi gambaran. Gangguan ini terjadi dalam bentuk yang didapat dan diwariskan (Bilezikian, Khan and Potts, 2011).…”

Intraoperative Parathyroid Hormone Assessment in Patients with Primary Hyperparathyroidism – One–Year Experience

“…Parathyroid carcinoma is rare and accounts for <1% of the reported cases of PHP (3). Parathyroidectomy is the treatment of choice in all cases of symptomatic PHP and includes excision of all hyperfunctioning parathyroid tissue while preserving normally functioning glands (4,5). In recent years, conventional neck exploration (CNE) has been replaced by minimally invasive parathyroidectomy (MIP) as the surgical approach of choice in patients with PHP (6,7).…”

Biochemical Effects from Treatment with Bisphosphonate and Surgery in Patients with Primary Hyperparathyroidism

“…In some small series, bisphosphonates have also been used to treat hypercalcemia due to pHPT. The documentation is sparse, though, and hypercalcemia caused by pHPT is not an accepted indication for treatment with bisphosphonates [18, 19]. In clinical situations, however, physicians sometimes prescribe bisphosphonates for the elderly and fragile patients who have pHPT‐related hypercalcemia if they consider the patients not suitable for surgical treatment.…”