Support for Early Surgery in Older Adults With Primary Hyperparathyroidism

NEW YORK (Reuters Health) – Parathyroidectomy is associated with a lower risk of fracture compared with non-surgical management among older adults with primary hyperparathyroidism (PHPT), a new study indicates.

“PHPT contributes to the development and progression of osteoporosis in older adults. The effectiveness of parathyroidectomy for reducing fracture risk in older adults is unknown,” researchers note in a paper in JAMA Internal Medicine.

“Currently, the majority of older adults with primary hyperparathyroidism are managed with observation and medications to treat complications of the disease, such as osteoporosis,” Dr. Carolyn Seib of Stanford University School of Medicine and Palo Alto VA Medical Center, in California, told Reuters Health by email.

“Our finding that parathyroidectomy provides a clinically meaningful reduction in the risk of fractures among patients of all ages, including those with and without osteoporosis and those who are frail and not frail, suggests that clinicians should give more consideration to definitive, operative management for all patients with primary hyperparathyroidism,” Dr. Seib said.

The study team compared the occurrence of fractures among 210,206 older adults (mean age, 75; 79% women) with PHPT; 63,136 (30%) underwent parathyroidectomy within a year of diagnosis and 147,070 (70%) were managed without surgery.

Compared with non-surgery patients, patients who had surgery were younger (mean age, 73.5 vs. 76.0 years; P<0.001), and more likely to be white, nonfrail and have a lower comorbidity burden. They were also less apt to have a history of osteoporosis and prior fracture.

On multivariable analysis, parathyroidectomy was associated with lower adjusted rates of any fracture (hazard ratio, 0.78; 95% confidence interval, 0.76 to 0.80) and hip fracture (HR, 0.76; 95% CI, 0.72 to 0.79).

At two, five and 10 years, parathyroidectomy was associated with adjusted absolute fracture-risk reductions of 1.2%, 2.8% and 5.1% respectively, compared with nonoperative management.

In multivariable analysis accounting for the competing risk of death, parathyroidectomy within one year of diagnosis was associated with a 16% lower adjusted risk of any clinical fracture (HR, 0.84; 95% CI, 0.82 to 0.85) and a 17% lower adjusted risk of hip fracture (HR, 0.83; 95% CI, 0.80 to 0.85), relative to no surgery within one year after diagnosis.

The number needed to treat to prevent one fragility fracture declined with time following surgery, from 149 after one year, 83 after two years, 36 after five years, and 20 after 10 years.

The benefit of parathyroidectomy on fracture risk remained significant regardless of age, sex, frailty category, history of osteoporosis or meeting or not meeting operative guidelines, “suggesting the skeletal benefits of parathyroidectomy are not limited to specific populations at higher risk of fractures,” Dr. Seib and colleagues write.

Dr. Seib told Reuters Health, “Our study is the first national study to document the long-term skeletal benefits of parathyroidectomy and is unique because the mean age of patients who were treated with surgery vs. observation was more similar than in prior studies.”

“Many patients diagnosed with primary hyperparathyroidism in their 60s and 70s have low risks of complications from surgery, so parathyroidectomy should be discussed with and offered to more of them to prevent complications from fractures that can occur if the disease remains untreated,” she added.

The authors of a linked editorial say the “valuable” findings by Dr. Seib and colleagues “add to the growing need to reexamine the 2014 National Institutes of Health consensus recommendations for patients for whom parathyroidectomy should be considered upfront.”

Those recommendations suggest that in the absence of symptomatic PHPT, surgery should only be considered when the asymptomatic individual is younger than 50 years. However, the American Association of Endocrine Surgeons’ 2016 guidelines suggest parathyroidectomy be considered for most asymptomatic patients.

“Revisiting expert guidelines to broaden the indications for parathyroidectomy to include older asymptomatic individuals may help to counteract the low referral rates for and decline in parathyroidectomy during the past 20 years and concomitantly reduce morbid fragility fracture incidence,” write Dr. Anand Habib of the University of California, San Francisco, and Dr. Mitchell Katz of NYC Health + Hospitals in New York.

“Decisions to pursue surgery should still be based on shared decision-making between patient and physician and consider the potential complications, including postoperative hypocalcemia, cervical hematoma, and recurrent laryngeal nerve injury. Still, the advent of minimally-invasive techniques has lowered the rates of these complications, and cure rates of 95% to 99% have been reported,” they point out.

“The findings of Seib and colleagues amplify what we have previously called for, electronic health record-driven clinical decision support tools to aid patient-physician shared decision-making and to ensure the implementation of evidence-based care,” the editorial writers conclude.

The study had no commercial funding and the authors have no relevant disclosures. Dr. Habib is editorial fellow with JAMA Internal Medicine and Dr. Katz is deputy editor of the journal.

SOURCE: https://bit.ly/3p7BMFz and https://bit.ly/2ZAaKOz JAMA Internal Medicine, online November 29, 2021.

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