How should I manage a patient with asymptomatic primary hyperparathyroidism, and when should I consider surgical intervention?

Management of a patient with asymptomatic primary hyperparathyroidism involves regular monitoring and supportive care. This includes annual measurement of serum calcium, vitamin D supplementation if deficient, assessment of renal function (eGFR and creatinine), and bone mineral density evaluation by DXA scan every 2 years or as advised by a specialist. Renal imaging should be arranged if renal stones are suspected, and cardiovascular risk assessment is recommended. Patients should be provided with information about their condition, symptoms to watch for, and lifestyle advice including hydration, diet, and exercise to reduce symptoms and prepare for possible future treatment. Referral to an endocrinologist or specialist is advised if symptoms develop or if biochemical or clinical parameters worsen.

Surgical intervention (parathyroidectomy) should be considered and referral made to a surgeon with expertise in parathyroid surgery if the patient has any of the following: symptoms of hypercalcaemia (such as thirst, frequent urination, constipation), evidence of end-organ disease (renal stones, fragility fractures, or osteoporosis), or an albumin-adjusted serum calcium level of 2.85 mmol/L or above. Surgery may also be considered even in the absence of these features, based on clinical judgement and patient preference, due to the potential to reduce long-term complications. Preoperative imaging (usually ultrasound and sestamibi scan) is used to guide surgical approach but surgery should proceed even if imaging is inconclusive, performed by an experienced surgeon. Postoperative monitoring includes serum calcium and PTH measurements to confirm surgical success and ongoing annual calcium monitoring.