Therapeutic Challenges for Elderly Patients with Primary Hyperparathyroidism

Case Reports in Endocrinology
08 Nov, 2019 ,

This case series presents the management of eight patients 85 years of age and older diagnosed with Primary hyperparathyroidism. A retrospective chart review of patients diagnosed with primary hyperparathyroidism were identified in a single institution. Those patients 85 years of age and older who were followed up for over one year were included in this case series. Eight cases of PHPT patients aged 88 ± 2.5 years old with a follow-up average of 5.6 ± 4.4 years were reported in the case series.

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We conducted a retrospective chart review of PHPT patients evaluated at Robert Wood Johnson University Hospital from January 2000 to September 2016. Our institution’s IRB provided approval for our investigations. There were 556 patients diagnosed with PHPT during this time.

The diagnostic criteria of PHPT included: (1) intact PTH > 65 pg/mL (normal range: 10–65 pg/mL) or inappropriately normal levels in the presence of elevated serum calcium, (2) serum calcium > 10.6 mg/dL (normal range: 8.5–10.4 mg/dL), and (3) 24-hour urinary calcium > 100 mg/day (normal range: 100–250 mg/day). Eight PHPT patients aged 85 years and older with follow-up duration longer than one year were included for this study. Patient demographics, baseline characteristics, clinical presentation and overall clinical follow-up were examined.

Eight patients diagnosed with PHPT at the age of 85 years or older were included. The average age at diagnosis was 88 ± 2.5 years old. The average follow-up duration was 5.6 ± 4.4 years. The average calcium was 11.3 ± 0.78 mg/dL, iPTH was 166 ± 154 pg/mL and 24-hour urine calcium was 183 ± 35.5 mg at the time of diagnosis. All eight patients met guidelines for surgery by the serum calcium levels >1 mg/dl upper limit of normal, creatinine clearance <60 cc/min or T-score <2.5.

Six PHPT patients were medically managed for one to eight years and two PHPT patients underwent parathyroid resection. The surgical group had a pre-operative serum calcium of 12.3 mg/dL while the medically managed group had an average of 10.9 mg/dL. For two patients treated surgically, one patient was cured with normal calcium and PTH levels but was only followed up for two years.

One patient had recurrence of PHPT five years after surgery and required medical management with cinacalcet, loop diuretic, and bisphosphonate for ten years. Six patients were managed medically for an average of 5.2 years with minimal complications. Only one of the six patients experienced PHPT-related mortality.

This patient had severe dementia, was on medical treatment for eight years, and passed away on hospice after a hip fracture. Of the other medically managed patients, three patients were managed with pharmaceutical therapy, one with bisphosphonate and two with cinacalcet. Two other patients were treated with nonpharmaceutical expectant management, which included oral hydration, discontinuation of HCTZ and maintaining physical activity. They had favorable outcomes after three to six years.