A 45-year-old woman is found to have serum calcium 11.4 mg/dL and PTH 92 pg/mL (normal 10–65) on routine screening. She is asymptomatic with no nephrolithiasis, serum creatinine is normal, and BMD T-score is −1.8 at the lumbar spine. Which management is recommended per current guidelines for asymptomatic primary hyperparathyroidism?
- A Observation with annual monitoring is appropriate as she meets no surgical criteria
- B Cinacalcet therapy should be initiated to normalize serum calcium
- C Parathyroidectomy is indicated because serum calcium exceeds 11.0 mg/dL ✓
- D Bisphosphonate therapy alone is sufficient management
Correct answer: C. Parathyroidectomy is indicated because serum calcium exceeds 11.0 mg/dL
Explanation
Per the 2022 Fourth International Workshop guidelines for asymptomatic primary hyperparathyroidism, surgical indication includes serum calcium >1 mg/dL above the upper limit of normal (i.e., >11 mg/dL if ULN is 10 mg/dL). This patient's calcium of 11.4 mg/dL meets that threshold. Other indications include eGFR <60, BMD T-score ≤−2.5, age <50, or nephrolithiasis/nephrocalcinosis. Cinacalcet lowers calcium but does not improve BMD or eliminate the tumor; it is for non-surgical candidates only.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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