Individual research recommendation details

Recommendation ID

NG132/1

Question

What is the clinical utility of bone turnover markers in the diagnosis and management of primary hyperparathyroidism?

Any explanatory notes
(if applicable)

Measuring vitamin D
No evidence was available on measuring vitamin D to assess primary hyperparathyroidism, so the recommendation is based on the committee's knowledge and experience.

The committee noted that vitamin D deficiency can lead to a rise in PTH level, exacerbate bone disease and increase postoperative risk. It is therefore important to assess and correct vitamin D for people with primary hyperparathyroidism. However, the committee were aware that vitamin D testing is not available to all primary care providers, and that waiting for vitamin D to be measured, and corrected if necessary, before seeking specialist advice could delay diagnosis. They therefore concluded that vitamin D measurement and correction are best carried out in secondary care.

Excluding familial hypocalciuric hypercalcaemia
The committee agreed that it is important to exclude familial hypocalciuric hypercalcaemia (FHH) because it needs no operative treatment. Evidence showed that the 3 tests recommended are equally accurate in the diagnosis of FHH. The committee were not able to recommend thresholds for these measurements because the evidence is inconsistent.

Assessment after diagnosis
The committee agreed that baseline assessment will help to determine optimal management in secondary care. They did not recommend phosphate measurement because improvements in PTH assays have reduced its usefulness.

The committee acknowledged the potential of bone turnover markers to enable earlier and more accurate diagnosis of primary hyperparathyroidism but were unable to make a recommendation because of a lack of evidence. They therefore made a research recommendation on bone turnover markers.

How the recommendations might affect practice
Measuring vitamin D in secondary care is expected to be a change in practice for some services. Current practice varies, partly because of the varying availability of vitamin D measurement in primary care. In primary care services where vitamin D measurement is available, vitamin D is being measured and deficiencies corrected before PTH is measured. By standardising practice and reducing delays in diagnostic testing, the committee expects improvements in the diagnosis of primary hyperparathyroidism and more prompt treatment for people with the condition.

Measuring urine calcium excretion in secondary care is current practice.

Source guidance details

Comes from guidance

Hyperparathyroidism (primary): diagnosis, assessment and initial management

Number

NG132

Date issued

May 2019

Other details