Abstract Background/Aims Primary hyperparathyroidism (PHPT) increases risk of fractures by reducing bone mineral density (BMD). NICE guidance NG 132 (2019) recommends parathyroidectomy as the definitive treatment modality in PHPT. Cinacalcet is used to control hypercalcaemia if surgery is inappropriate. Anti-osteoporosis pharmacological therapies have an important place in management, especially if parathyroidectomy is contraindicated. We evaluated the management of low BMD in PHPT patients at our centre against NICE guidance and identified areas for improvement. Methods A retrospective audit of all PHPT patients reviewed in the osteoporosis service between 2000 and 2025 at Basildon University Hospital was conducted as per PDSA methodology. Data on demographics, comorbidities, fracture history, BMD, and treatment modalities were collected using electronic patient records. Results Sixty-four patients were assessed; 87.5% (n = 56) female, most aged 70-89 years (76.5%, n = 49). Common comorbidities were arthritis (23.2%, n = 15), vitamin D deficiency (16.2%, n = 10), CKD/COPD (11.6%, n = 7), and polymyalgia rheumatica (5.8%, n = 4). Fragility fractures were found in in 64% (n = 41) of patients, wrist (30%, n = 19), upper limb (20%, 13), lower limb (18.8%, n = 12), vertebra (16.6%, n = 11), and neck of femur (13.3%, n = 9). Parathyroidectomy was performed in 32.8% (n = 21). Pharmacological therapy predominated, with cinacalcet in 15.6% (n = 10), alendronic acid 68.5% (n = 37), denosumab 37.5% (n = 24), zoledronic acid 18.5% (n = 10), and risedronate in 3.7% (n = 2). The treatment duration range was from 6 to 23 years, with 14 patients (21.8%) given a drug holiday. Our patients received sequential anti-osteoporosis treatments as per the standard treatment guidelines. As per the summary in table 1, denosumab and zoledronic acid produced consistent spine and hip BMD gains compared to surgery. Parathyroidectomy improved spine BMD, but saw hip decline. Denosumab showed the greatest overall benefit, while alendronate was less effective. Conclusion Our audit highlights the role of conservative management with denosumab and zoledronic acid, showing superior BMD endpoints both at hip and spine compared to parathyroidectomy. Pharmacological therapies are preferable to surgery in the majority of patients due to comorbidities and frailty. We look to standardise local care pathways in line with national guidance to optimise treatment strategies for the subset of patients who are not candidates for surgical options. Disclosure K.K. Garg: None. T. Jones: None. A. Nandagudi: None.
Garg et al. (Wed,) studied this question.