A 58-year-old woman is found to have serum calcium of 11.2 mg/dL on routine testing. She is asymptomatic. Intact PTH is elevated at 98 pg/mL (normal 15 to 65). Twenty-four-hour urine calcium is 280 mg. Serum creatinine is normal. DEXA scan shows T-score of negative 2.6 at the femoral neck. Which is the most appropriate next step?
- A Observation with annual serum calcium and creatinine
- B Cinacalcet therapy
- C Parathyroidectomy ✓
- D Bisphosphonate therapy
Correct answer: C. Parathyroidectomy
Explanation
According to the Fourth International Workshop guidelines, parathyroidectomy is indicated in asymptomatic primary hyperparathyroidism when T-score is negative 2.5 or less at any site. Other surgical criteria include serum calcium more than 1 mg/dL above normal, creatinine clearance below 60 mL per minute, or 24-hour urine calcium exceeding 400 mg. This patient meets the bone density criterion. Cinacalcet is reserved for patients who are not surgical candidates.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.