Therapeutic challenges in elderly patients with symptomatic hypercalcaemia caused by primary hyperparathyroidism

Background: Hypercalcaemia resulting from primary hyperparathyroidism (PHPT) can cause a wide range of symptoms, including cognitive disorders, psychiatric symptoms and muscle weakness. Parathyroid surgery is the only definite cure for PHPT. When surgery is contraindicated or patients decide against it, several non-surgical treatment options are available. Objective: To illustrate the treatment options of symptomatic hypercalcaemia caused by PHPT in the elderly and discuss these options in consideration of the available evidence. Design: Consecutive case series. Setting: University hospital. Patients: Four older patients aged 79-87 years with symptomatic hypercalcaemia resulting from PHPT. Results: Three patients had a parathyroid adenoma shown on a sestamibi scan. Normocalcaemia and resolution of symptoms was achieved by different treatment scenarios encompassing forced saline hydration, forced diuresis, intravenous pamidronate and cinacalcet, a calcimimetic drug. In one patient, no parathyroid abnormalities were revealed with imaging. Treatment with cinacalcet resulted in normocalcaemia and a strong improvement of symptoms. Conclusion: In clinical practice, different treatment scenarios are chosen for the treatment of elderly patients with symptomatic hypercalcaemia caused by PHPT. The introduction of cinacalcet offers a new treatment paradigm. We propose to apply cinacalcet preceding elective surgery as an alternative option to standard therapy or as maintenance dose when surgery is not possible.