Bone disease in primary hyperparathyroidism.

Primary hyperparathyroidism (PHPT) is a disease of high bone turnover, decreased bone mineral density (BMD) especially at cortical sites, and increased risk of fractures at all skeletal sites. Early diagnosis during the last decades resulted in milder forms of bone involvement. New methods of imaging and validation such as high resolution peripheral quantitative computed tomography and trabecular bone score provide evidence of disturbed bone microarchitecture and explain further the increased risk of fractures at both cortical and trabecular skeletal sites. Parathyroidectomy has a long-term beneficial effect on the skeleton and is probably prudent to refer PHPT patients for surgery in all cases where increased bone fragility is suspected. Bisphosphonates (BPs), mainly alendronate, have been proved as reasonable choices for BMD improvement while cinacalcet has no effect on bone strength in PHPT. Combination of BPs and cinacalcet, is a valid therapeutic approach from a pathophysiological point of view at least in terms of bone health, however, an adequately powered study to prove it is lacking. Adequate dietary calcium intake and vitamin D supplementation is advised as in the general population for the skeletal integrity of PHPT patients albeit with a close monitoring of serum and urinary calcium levels.