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endo.hyperparathyroidism.v1PRODUCTION
endo.hyperparathyroidism.v1

Hyperparathyroidism (primary, secondary, tertiary)

endocrinologychronicsubacuteacuteadult
Hard-required inputs
0 / 12
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm pHPT — hypercalcemia + non-suppressed PTH; rule out FHH via urine Ca:Cr ratio (AACE/ACE 2022; 4th International Workshop Bilezikian 2014)

Inputs
3
Actions
0
Advance rule
Set
Advance when

Diagnosis confirmed and FHH excluded

Patient inputs (16)

Age <50 favours surgery (4th International Workshop Bilezikian JCEM 2014 PMID 25162666; AACE/ACE 2022)

Drug-induced PTH elevation (AACE/ACE 2022; 4th International Workshop 2014 exclusion)

Reconciliation (AACE/ACE 2022)

Confirm hypercalcemia; ionized preferred in critical illness (AACE/ACE 2022 PHPT; 4th International Workshop 2014)

Inappropriate or high PTH with hypercalcemia diagnostic (AACE/ACE 2022 PHPT diagnostic criteria)

Low phos in primary; high in secondary CKD (KDIGO 2017 CKD-MBD; AACE/ACE 2022)

Bone turnover marker (4th International Workshop 2014; NICE 2019)

Repletion required before surgery; deficiency raises PTH (AACE/ACE 2022; Bilezikian JCEM 2014)

Hypomag mimics hypoparathyroidism (AACE/ACE 2022 PHPT workup)

CKD impacts surgical criteria (eGFR <60 = criterion per 4th International Workshop 2014) + secondary HPT (KDIGO 2017)

Differentiate FHH — urine Ca:Cr <0.01 (4th International Workshop Bilezikian 2014; AACE/ACE 2022)

T-score ≤-2.5 = surgical criterion (4th International Workshop 2014; AACE/ACE 2022)

Adenoma localisation pre-op (AAES 2016 PMID 27532368; AACE/ACE 2022)

Reoperative or non-localising sestamibi (AAES 2016; AACE/ACE 2022)

Hyperthyroid mimicker (AACE/ACE 2022 differential)

Nephrolithiasis = surgical indication (4th International Workshop 2014; NICE 2019)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateninghypercalcemic_crisis
    Ca >14 with AKI / AMS / arrhythmia
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresbm_aaes_surgical_criteria_met
    pHPT meeting SBM 2014 / AAES 2016 surgical criteria
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereparathyroid_carcinoma_concerns
    Ca >14, PTH >5× upper limit, palpable neck mass, RLN palsy
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehungry_bone_postop
    Postop Ca <8 with hypophosphatemia + low Mg
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretertiary_hpt_post_kt
    Persistent autonomous HPT after kidney transplant
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatefhh_suspected
    Urine Ca:Cr ratio <0.01
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateshpt_ckd_pth_above_target
    CKD G3a–5D with PTH > KDIGO target
    Trigger could not be auto-evaluated — needs clinician judgement.

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INITIAL_WORKUPrequiredDrives severity classification
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Recommended regimen

Medical management of primary HPT
axis: phpt_medical
Selected axis "Medical management of primary HPT" by default fallback (first axis)
  • cinacalcet
    second line
    calcimimetic
    30 mg, titrate to 90 mg q6h • PO • daily, titrate to BID/TID
    triggers: non_surgical_pHPT, parathyroid_carcinoma, severe_hypercalcemia
    Reduces calcium; FDA-approved for non-surgical pHPT (AACE/ACE 2022; 4th International Workshop 2014 medical management)
    rxcui 407990
  • alendronate
    add on
    oral_bisphosphonate
    70 mg weekly • PO • weekly
    triggers: osteoporosis_with_pHPT
    Improves BMD; does not lower Ca substantially (Khan JCEM 2017; AACE/ACE 2022)
    rxcui 46041
  • zoledronic_acid
    second line
    IV_bisphosphonate
    4 mg IV (5 mg for osteoporosis) • IV • q3–4 wks for hypercalcemia of malignancy; q1y for OP
    triggers: hypercalcemia_severe, osteoporosis
    Aggressive Ca lowering; ONJ risk (AACE/ACE 2022; NICE 2019)
    rxcui 77655
  • denosumab
    add on
    rankl_inhibitor
    60 mg q6m for OP; 120 mg q4w for hypercalcemia of malignancy • SC • q6m or q4w
    triggers: osteoporosis_or_bone_lesion
    Alternative to bisphosphonate; no renal limit; ONJ risk (AACE/ACE 2022)
    rxcui 993449
  • cholecalciferol
    add on
    vitamin_D
    1000–2000 IU daily • PO • daily
    triggers: vit_D_lt_30
    Repletion before surgery to optimise outcomes (Bilezikian JCEM 2014; AACE/ACE 2022)
    rxcui 2418

outpatient playbook — drug actions (3)

  1. 1. vit D repletion
    1000–2000 IU/d (or stoss) • PO • daily
    trigger: Vit D <30
    Pre-op optimisation (Bilezikian JCEM 2014; AACE/ACE 2022)
  2. 2. cinacalcet
    30–90 mg • PO • daily / BID
    trigger: Non-surgical pHPT or carcinoma
    Calcium lowering (AACE/ACE 2022; 4th International Workshop 2014)
  3. 3. bisphosphonate or denosumab
    alendronate 70 mg/wk OR denosumab 60 mg q6m • PO/SC • weekly or q6m
    trigger: Osteoporosis
    Bone protection (AACE/ACE 2022; Khan JCEM 2017)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Incidental hypercalcemia on routine labs (4th International Workshop Bilezikian JCEM 2014); Recurrent calcium-containing kidney stones (4th International Workshop 2014 surgical criterion); Fragility fracture or osteoporosis (4th International Workshop 2014 T-score criterion).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Hyperparathyroidism (primary, secondary, tertiary)** (endo.hyperparathyroidism.v1).
Phenotype framing: Primary HPT vs FHH vs malignancy (PTHrP / lytic) vs granulomatous vs vit D tox vs lithium (AACE/ACE 2022 differential; 4th International Workshop 2014)
Scope: Confirm pHPT — hypercalcemia + non-suppressed PTH; rule out FHH via urine Ca:Cr ratio (AACE/ACE 2022; 4th International Workshop Bilezikian 2014)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Medical management of primary HPT**.
1. cinacalcet 30 mg, titrate to 90 mg q6h PO daily, titrate to BID/TID (calcimimetic, second line) — Reduces calcium; FDA-approved for non-surgical pHPT (AACE/ACE 2022; 4th International Workshop 2014 medical management)
2. alendronate 70 mg weekly PO weekly (oral_bisphosphonate, add on) — Improves BMD; does not lower Ca substantially (Khan JCEM 2017; AACE/ACE 2022)
3. zoledronic_acid 4 mg IV (5 mg for osteoporosis) IV q3–4 wks for hypercalcemia of malignancy; q1y for OP (IV_bisphosphonate, second line) — Aggressive Ca lowering; ONJ risk (AACE/ACE 2022; NICE 2019)
4. denosumab 60 mg q6m for OP; 120 mg q4w for hypercalcemia of malignancy SC q6m or q4w (rankl_inhibitor, add on) — Alternative to bisphosphonate; no renal limit; ONJ risk (AACE/ACE 2022)
5. cholecalciferol 1000–2000 IU daily PO daily (vitamin_D, add on) — Repletion before surgery to optimise outcomes (Bilezikian JCEM 2014; AACE/ACE 2022)

Setting playbook (outpatient) — Confirm, exclude FHH, decide surgery vs medical, manage long-term
6. vit D repletion 1000–2000 IU/d (or stoss) PO daily — Vit D <30 (Pre-op optimisation (Bilezikian JCEM 2014; AACE/ACE 2022))
7. cinacalcet 30–90 mg PO daily / BID — Non-surgical pHPT or carcinoma (Calcium lowering (AACE/ACE 2022; 4th International Workshop 2014))
8. bisphosphonate or denosumab alendronate 70 mg/wk OR denosumab 60 mg q6m PO/SC weekly or q6m — Osteoporosis (Bone protection (AACE/ACE 2022; Khan JCEM 2017))

Non-pharmacologic actions:
- Surgical referral if SBM/AAES criteria (4th International Workshop 2014; AAES 2016)
- Hydration counselling (AACE/ACE 2022)
- Sodium 100 mEq/d limit; calcium intake 1000-1200 mg/d (4th International Workshop 2014)
- Avoid lithium / thiazide if possible (AACE/ACE 2022; 4th International Workshop 2014)

AVOID / contraindication checks:
- Cinacalcet monitor Ca q1w
- Bisphosphonate eGFR 30
- Denosumab hypocalcemia replete Ca first
- Bisphosphonate ONJ dental screen

Monitoring

Regimen monitoring:
- Ca PTH q3m — 4th International Workshop 2014; AACE/ACE 2022
- eGFR q6m — 4th International Workshop 2014; AACE/ACE 2022
- DEXA q1 2y — 4th International Workshop 2014; AACE/ACE 2022

Setting (outpatient) monitoring:
- Ca + PTH q3m if not surgical (4th International Workshop 2014 surveillance; AACE/ACE 2022)
- DEXA q1-2 y (4th International Workshop 2014; AACE/ACE 2022)
- 24-h urine Ca q1 y (4th International Workshop 2014)

Follow-up plan: Endo / surgery follow-up; family screen if MEN; bone health long-term (AACE/ACE 2022; 4th International Workshop 2014)
- Close-out criterion: Follow-up booked

Monitoring phase: Calcium, PTH, eGFR, DEXA q1-2 yr, urine Ca q1 yr; postop hungry bone monitoring (4th International Workshop 2014 surveillance; AACE/ACE 2022)

Disposition

Current setting: outpatient — Confirm, exclude FHH, decide surgery vs medical, manage long-term

Disposition criteria:
- Continue surveillance or post-op follow-up (4th International Workshop 2014; AACE/ACE 2022)

Escalation triggers (move to higher acuity):
- Crisis → ED (AACE/ACE 2022 crisis management)
- Carcinoma suspected → surgery + neck imaging (AAES 2016; AACE/ACE 2022)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Ca >14 with AKI / AMS / arrhythmia
- [SEVERE] pHPT meeting SBM 2014 / AAES 2016 surgical criteria
- [SEVERE] Ca >14, PTH >5× upper limit, palpable neck mass, RLN palsy

Citations

- SBM 2014 4th International Workshop Asymptomatic pHPT (Bilezikian); AAES 2016 surgical guideline; KDIGO 2017 CKD-MBD [PMID:25162666](https://pubmed.ncbi.nlm.nih.gov/25162666/)
- Cited evidence (PMID 27532368) [PMID:27532368](https://pubmed.ncbi.nlm.nih.gov/27532368/)
- Cited evidence (PMID 30675420) [PMID:30675420](https://pubmed.ncbi.nlm.nih.gov/30675420/)
- Cited evidence (PMID 23121374) [PMID:23121374](https://pubmed.ncbi.nlm.nih.gov/23121374/)

Last reconciled with current guidelines: 2026-05-22.
References
  • SBM 2014 4th International Workshop Asymptomatic pHPT (Bilezikian); AAES 2016 surgical guideline; KDIGO 2017 CKD-MBD — PMID:25162666
  • Cited evidence (PMID 27532368) — PMID:27532368
  • Cited evidence (PMID 30675420) — PMID:30675420
  • Cited evidence (PMID 23121374) — PMID:23121374