A 52-year-old woman comes to the office for follow-up after a forearm fracture. She experienced a nondisplaced radial fracture in a ground-level fall a week ago, and was treated with casting in the emergency department. The patient has a history of chronic constipation but has had no polyuria, bone pain, hematuria, or headaches. Medical history is notable for borderline hypertension that has been stable for several years with dietary modification. Her only medications include calcium and vitamin D supplements that she started after experiencing menopause a year ago. The patient has a 15-pack-year smoking history but quit 20 years ago; she does not use alcohol or illicit drugs. Her mother has osteoporosis and her father had type 2 diabetes mellitus and hypertension. Blood pressure is 157/98 mm Hg and pulse is 72/min. BMI is 28 kg/m². Physical examination shows a cast on the right forearm but is otherwise unremarkable. Laboratory results are as follows: Serum calcium a year ago was 10.9 mg/dL. DXA reveals a T-score of −2.6 at the lumbar spine and −1.8 at the femoral neck. Which of the following is the best management for this patient?

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Explanation: 11ec2b69_bec1_6b60_8f63_bd393af4b0ba_MD0005_00 This patient with a recent fracture and evidence of osteoporosis on DXA (T-score <−2.5) has mild hypercalcemia with an elevated parathyroid hormone level (ie, parathyroid hormone-dependent hypercalcemia), most likely due to primary hyperparathyroidism (PHPT). (Familial hypocalciuric hypercalcemia can also cause parathyroid hormone-dependent hypercalcemia but is much less common and would be associated with urinary calcium excretion <200 mg/day and a positive family history.) PHPT is most commonly due to a parathyroid adenoma but may also be caused by multiglandular parathyroid hyperplasia or, rarely, parathyroid carcinoma. PHPT usually is asymptomatic or causes only mild, nonspecific symptoms (eg, constipation); it typically is detected on testing performed for other reasons.Parathyroidectomy is recommended for patients who have symptomatic hypercalcemia (eg, bone pain, abdominal pain, psychiatric symptoms), complications (eg, osteoporosis, nephrolithiasis, chronic kidney disease), or elevated risk for complications (eg, moderate to severe hypercalcemia). In addition, patients age <50 are likely to develop complications later in life and should undergo parathyroidectomy even if they are asymptomatic. This patient has osteoporosis with a fragility fracture and warrants parathyroidectomy. (Choice A) Bisphosphonate use is common in postmenopausal women with osteoporosis. However, in patients with PHPT, although short-term use of bisphosphonates can increase bone density, long-term data showing a reduced fracture risk are not available and there is concern about the risks of prolonged use (eg, osteonecrosis of the jaw). Bisphosphonates may be considered in patients with PHPT who are high-risk surgical candidates or refuse surgery. (Choice B) Combined estrogen-progestin hormone replacement therapy can improve bone density in postmenopausal women with PHPT. However, there is no evidence showing a reduced fracture risk. In light of the additional risks (eg, breast cancer, stroke), hormone replacement is not advised as primary therapy in PHPT. (Choice D) Asymptomatic patients with PHPT who do not have indications for parathyroidectomy can be followed with periodic serum calcium, creatinine, and DXA. This patient has osteoporosis, which may worsen without surgical intervention. (Choice E) Thiazide diuretics have a mild calcium-sparing effect and are often recommended for the management of hypertension in patients at risk for osteoporosis. However, they can worsen hypercalcemia in PHPT and should be avoided. Educational objective: Parathyroidectomy is recommended for patients with primary hyperparathyroidism who have symptomatic hypercalcemia, complications (eg, osteoporosis, nephrolithiasis, chronic kidney disease), or increased risk for complications (eg, moderate to severe hypercalcemia). In addition, patients age <50 are likely to develop complications later in life and should undergo parathyroidectomy. References: Guidelines for the management of asymptomatic primary hyperparathyroidism: summary statement from the Fourth International Workshop. (http://www.ncbi.nlm.nih.gov/pubmed/25162665)

A 52-Year-Old Woman Comes to the Office for Follow-Up After