Melanie Cole (Host): Primary hyperparathyroidism is a common disorder of mineral metabolism characterized by incompletely regulated excessive secretion of parathyroid hormone from the parathyroid glands. My guest today is Dr. Herbert Chen. He’s the Chairman in the Department of Surgery and the Surgeon in Chief at UAB Medicine. Welcome to the show, Dr. Chen. So, give us a little bit of a summary of hyperparathyroidism.

Dr. Herbert Chen (Guest): Well, hyperparathyroidism is a very common disorder. In fact, it’s one of the most common endocrine disorders in the population and it frequently is underdiagnosed. Part of the reason that I want to speak about it today is that I believe there are many, many people that are probably listening today in the state and in the region who have hyperparathyroidism and may be suffering consequences of the disease and not been diagnosed. So, hyperparathyroidism, as you alluded to, is a disease of metabolism but it can affect many of the organs in your body and affect how you feel, and the most common symptoms are fatigue, difficulty concentrating, memory issues, as well as kidney stones, osteoporosis, and musculoskeletal pain, and so forth. So, I do think it really impacts patients’ quality of life and, as a surgeon, we can easily fix this with a simple procedure.

Melanie: Do we know what causes it?

Dr. Chen: Most commonly, it is a tumor in one of the four parathyroid glands in your neck. What happens is the tumor secretes excessive parathyroid hormone, which results in your body mobilizing calcium from your bones into the blood. The long-term consequence is that patients will develop osteopenia, then osteoporosis, and the high levels of calcium in the blood causes symptoms such as, as I mentioned before, the fatigue, abdominal pain, joint pain, muscle pain, inability to concentrate, frequent urination. When we look at patients with this disorder, the vast majority of studies that we have done and others have done show that the vast majority--well over 90% of patients--who have hyperparathyroidism have some physical consequence or symptom of the disease.

Melanie: When we’re looking at diagnosis, if you’re looking at blood calcium or PTH, are you also doing bone density testing? Give us a little diagnostic tools to use.

Dr. Chen: So, I think the most frequent scenario that hyperparathyroidism is diagnosed is that patient is seeing their primary care provider and an elevated calcium is detected. Now, we’ve done an interesting study here at UAB when we look at patients with that, the vast majority of patients, no further workup is done. And, I have seen many, many patients who this has been going on for years until it’s diagnosed. So, what I tell and when I’m trying to educate more of our providers, is that if a patient has an elevated calcium, the most common cause is hyperparathyroidism. So, the next test is to order a parathyroid hormone. And, if both of them are elevated, they definitely have hyperparathyroidism. If the calcium is up and the parathyroid hormone level is even in the high end of normal, the patient has the disease, because if you have a very high calcium, if there’s another cause of the hypercalcemia, the parathyroid hormone should be suppressed, close to zero. So, I think that is a common scenario where physicians can misdiagnose hyperparathyroidism and not detect it. Now, getting to your question about the bone density, once you make the diagnosis of hyperparathyroidism, it is useful to get a bone density study to measure if the patient has had any impact on their bones and if they have, that’s even a stronger case for intervention.

Melanie: Has this disease become milder over the years?

Dr. Chen: Well, I think what has happened is that as we have educated more and more physicians about making the diagnosis, is that in the past, patients wouldn’t be diagnosed until they really had severe disease. With a little better education, we are detecting the disease at an earlier stage, and some people would call it mild disease, where the laboratory values have not gotten as bad. But, interestingly, from research that we have done, and others actually have done in the field, is that patients, even when they have “mild” disease, there are severe physical manifestations and impact on quality of life that are already occurring.

Melanie: Well, so speak about some of those, and also, we’re seeing a lot more vitamin D deficiency. Is there a test that’s recommended for vitamin D as it goes along with all of these other studies?

Dr. Chen: Yes, and I’m glad you mentioned that. So, when we see someone with potential hyperparathyroidism, we also check a vitamin D level. One of the causes of what we call “secondary hyperparathyroidism” is vitamin D deficiency, which can be easily treated by supplementing or giving the patient vitamin D. But, vitamin D deficiency can actually mask hyperparathyroidism. So, if you have a patient, for instance, whose calcium is actually normal and their parathyroid hormone level is elevated, one cause could be vitamin D deficiency and if you treat the vitamin D deficiency, and if it’s vitamin D deficiency only, you should see a drop in their parathyroid hormone back to normal and their calcium level should stay normal. However, if you have a patient who has both hyperparathyroidism and vitamin D deficiency, if you then treat it and if they have hyperparathyroidism, the calcium will go up. What is happening in that scenario is the vitamin D deficiency is lowering the calcium in the blood, but once you treat it, the calcium starts to go up. So, we do check vitamin D in addition to the labs, and there’s a lot of vitamin D deficiency here in Alabama, for sure, but what we’re finding is if you have an elevated parathyroid hormone and vitamin D deficiency concomitantly, often both diseases - vitamin D and hyperparathyroidism that needs surgical treatment - are present.

Melanie: So, then, let’s talk about treatment, now. What is the primary management and first line of defense that you would go to?

Dr. Chen: Sure. So, the only curative treatment for hyperparathyroidism is surgery. As I alluded to before, the most common cause is a single tumor of one of the parathyroid glands. Other causes are actually multiple tumors occurring in multiple parathyroid glands. So, again, the only curative therapy is surgery. I think in the past, primary care providers have been reluctant to send patients for intervention because it was viewed as, “It’s got to be pretty extreme before I send someone to surgery.” But, in my mind, that doesn’t make any sense because would we ever wait to treat diabetes until there’s been a complication of the disease? No. We would treat it up front. So, there’s no problem with doctors thinking, “Well, we’ve got to treat diabetes and give the patient insulin,” but when it comes to actually the treatment as a surgical procedure, there is just a perception, there must be a higher bar to send for treatment. But, parathyroid surgery, unlike some of the more sort of complicated and bigger operations that we do as surgeons, is a very straightforward outpatient procedure by which where the operation takes less than an hour to perform. It’s done as an outpatient procedure so the patient comes in that day of surgery, has surgery, goes home the same day. And, basically, I tell the patients that I want them to take it easy one week after surgery, no heavy exercise, heavy lifting, but they can do the things they normally need to do, eat, drink, talk, walk, even go back to work, but in a week they can do anything. So, it’s really a minor procedure that can have a significant impact on patients’ lives and so it is really straightforward and what we hope by in doing this podcast and educating is that I’m not saying all patients should have surgery, because we have to look at each individual patient as their own and measure what their risk is and everything, but at least we should have when the diagnosis is made, the patient should be sent to surgeon to actually talk about the options of curing it with surgery or not.

Melanie: What about medicational intervention?

Dr. Chen: Well, I mean, there’s nothing that cures the disease but surgery, as mentioned. So, if a patient has a very, very high calcium as a result of the disease, we may put them on some medications to temporarily get the calcium under control so it doesn’t-- when patients have very, very high calcium, it can cause problems with their heart with arrhythmias and stuff like that which we don’t want, but that is the minority of patients who present. Most of them have calciums that aren’t super high and don’t need any medical intervention prior to surgery. And, any medical intervention that you attempt to treat hyperparathyroidism really is just temporizing and not effective long term.

Melanie: So, then, wrap it up for us, Dr. Chen, what you want other providers to know about hyperparathyroidism and recognizing this condition so that it can be treated and managed effectively.

Dr. Chen: Well, I think that the points that I’d like to drive home is that one, it’s very common; two is that if you have a patient with an elevated calcium, don’t blow it off because there’s a good chance they have hyperparathyroidism. And, based upon the patient’s I see, and I know the patients that many of my colleagues see, the disease is already effecting them because the vast majority have symptoms such as fatigue and they all report a reduced quality of life. So, if you refer them for possible surgery, which is a straightforward outpatient procedure, you can have a huge impact on quality of life and prevent osteoporosis and other complications down the road. So, again, I think it’s all about recognizing that the disease is there because when you talk to patients, everyone probably has a little bit of fatigue, right? And, some of these symptoms are very non-specific, but recognizing that that one calcium that you may get is elevated, you need to please follow up with it because you may, by diagnosing the disease and sending the patient to us for treatment, you may have a big impact on that patient’s life.

Melanie: So, in the last few minutes, Dr. Chen, how can a community physician refer a patient to UAB Medicine?

Dr. Chen: Well, there’s a number of ways. They can just call my office, is one. But, we have a multidisciplinary team that takes care of this that handles referrals through my office and we have many talented surgeons who can do the operation. And, I’m happy to facilitate any of that by either by email, call my office-- we’re happy to get the patient to the right person and they can go through the MIST line or whatever. Any way to get to UAB, if they want to mention my name saying, “Hey, I heard this podcast. I want to try to get this patient the right surgeon and Dr. Chen said he would help me.” I’m happy to do that.

Melanie: And that number is 1-800-UAB-MIST. And, tell us about your team, Dr. Chen. Why is UAB so great to work with?

Dr. Chen: Well, I think that we really have a talented team of endocrinologists, radiologists, and surgeons who treat a variety of endocrine disorders including hyperparathyroidism. And one of the advantages of coming to UAB, who has a national and international reputation in this disease, is you will be treated by the team that has a lot of experience with this disease and we all know that the more experience you have, the more likely the treatment will be successful, and that’s definitely true in surgery. For example, I’ve done over 2,000 of these operations and so I’ve seen a lot and I’ve done a lot, and so the chances of you being treated and curing the disease is much higher if you go to a place with a lot of experience. That’s what we have here at UAB.

Melanie: Thank you so much for being with us today, Dr. Chen. You’re listening to UAB Medcast. For more information on resources available at UAB Medicine, you can go to www.UABmedicine.org/physician. That’s www. UABmedicine.org/physician. This is Melanie Cole. Thanks so much for listening.