Parathyroidectomy remains the definitive treatment for primary hyperparathyroidism (PHPT), achieving biochemical cure in around 96% of cases and improving bone mineral density; it is recommended for symptomatic disease and for asymptomatic patients with marked hypercalcemia, reduced renal function, kidney stones, osteoporosis, or younger age. For patients who are not surgical candidates, medical management centers on the calcimimetic cinacalcet, which effectively lowers serum calcium and PTH (without improving bone density), and antiresorptive agents (alendronate, denosumab), which increase bone mineral density — though their effect on fracture risk remains uncertain, and cinacalcet and bone-directed therapy are often complementary rather than interchangeable. Contemporary international guidelines have refined the thresholds for surgery versus surveillance, and genetic evaluation is increasingly used to identify heritable syndromes and avoid inappropriate surgery.
Further reading: efficacy and safety of medical vs surgical therapy in PHPT (Ye et al., JBMR 2022); management of primary hyperparathyroidism (Bilezikian et al., JBMR 2022).