Executive summary
- Think primary hyperparathyroidism in persistent hypercalcaemia, especially with renal stones, osteoporosis, constipation, thirst/polyuria, or a compatible incidental biochemical pattern.
- Primary care start point: if albumin-adjusted calcium is 2.6 mmol/L or above, or 2.5 mmol/L or above with suggestive features, repeat the calcium and consider PTH-based assessment.
- Surgery is the definitive treatment for many patients and the referral threshold is intentionally quite low in NG132.
Assessment after biochemical suspicion
- Do not rely on one mildly abnormal calcium if the picture is uncertain; repeat testing is part of the diagnostic pathway.
- Once probable/confirmed, NICE advises vitamin D measurement, renal assessment, DXA assessment (lumbar spine, distal radius, hip), and renal tract ultrasound.
- Important differential: familial hypocalciuric hypercalcaemia should be considered, with urinary calcium excretion testing used to help distinguish it from primary hyperparathyroidism.
When to refer for parathyroid surgery
- Refer to a surgeon with parathyroid expertise if there are symptoms of hypercalcaemia such as thirst, excessive urination, or constipation.
- Refer if there is end-organ disease such as renal stones, fragility fracture, or osteoporosis.
- Refer if albumin-adjusted calcium is 2.85 mmol/L or above.
- Even without these features, NICE says surgical referral can still be considered after confirmed diagnosis.
- If managed non-surgically, monitor albumin-adjusted calcium and eGFR/creatinine annually, consider DXA every 2–3 years, and investigate possible renal stones when relevant.
Frequently asked questions
At what calcium level does NICE clearly recommend surgical referral?
At an albumin-adjusted serum calcium of 2.85 mmol/L or above, or earlier if symptoms or end-organ disease are present.
What end-organ complications count?
Renal stones, fragility fractures, and osteoporosis are explicitly named by NICE as indications for referral to a surgeon with parathyroid expertise.
Can people still be referred if they are “asymptomatic”?
Yes. NICE says referral for surgery can still be considered even when the explicit mandatory features are absent.
Transparency
This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.