Abstract
Background: Long-term lithium use in psychiatric patients may lead to lithium associated hyperparathyroidism (LAH). Although anecdotal case reports have appeared, an evidence based algorithm for management of LAH is lacking. Methods: A comprehensive literature search was performed (1973-2010) using PubMed with keywords; “lithium” “hypercalcemia” “hyperparathyroidism” “sestamibi” “intra-operative parathyroid hormone (IOPTH) monitoring” “parathyroidectomy” and “medical management”. All English language publications addressing etiology and clinical management issues concerning LAH were critically analyzed. Results: Lithium associated hyperparathyroidism occurs in 4.3% - 6.3% of chronic lithium users compared to the general population which has an incidence of 0.5% - 1%. 194 cases of LAH have been reported which includes 10 patients (5%) treated medically and 170 patients (88%) who underwent parathyroidectomy. No details were available for 14 patients (7%). Among parathyroidectomy patients, 104 (59%) had adenomatous disease and 66 (39%) had multiglandular hyperplasia. Preoperative localization studies were utilized in only 22 patients (13%) and IOPTH monitoring was reported in only 3 studies (32 patients, 19%). Among surgical patients, bilateral neck exploration (BNE) was the most common approach performed in 162 patients (95%); focused neck exploration was utilized in only 8 patients (5%). Parathyroidectomy normalized LAH biochemical changes in nearly all patients (90% - 97%) in the early post-operative period, but recurrent hyperparathyroidism occurred in 8% - 42% of patients. Conclusion: LAH is an under appreciated and poorly understood endocrine disorder. LAH has a higher incidence of multiglandular disease and bilateral neck exploration is mandatory in majority for disease control. Nonsurgical approaches may be useful in select patients on short-term lithium therapy.
Highlights
Lithium Carbonate (Li+) is the preferred and most efficacious therapy for acute treatment and maintenance therapy for bipolar depressive disorder, and is a useful adjunct in unipolar depression [1,2]
Lithium associated hyperparathyroidism occurs in 4.3% - 6.3% of chronic lithium users compared to the general population which has an incidence of 0.5% - 1%. 194 cases of lithium associated hyperparathyroidism (LAH) have been reported which includes 10 patients (5%) treated medically and 170 patients (88%) who underwent parathyroidectomy
Lithium use is associated with an increased incidence of hyperparathyroidism (4.3% - 6.3%) and a female preponderance (F: M 4:1) compared to primary hyperparathyroidism in the general population (0.5% - 1% and F: M 3:1)
Summary
Lithium Carbonate (Li+) is the preferred and most efficacious therapy for acute treatment and maintenance therapy for bipolar depressive disorder, and is a useful adjunct in unipolar depression [1,2]. Chronic lithium therapy is associated with hyperparathyroidism (LAH) characterized by hypercalcemia, hypermagnesemia, reduced urinary calcium, and elevated serum PTH levels often with enlarged parathyroid gland(s) [3,4]. Rare case reports and a limited number of reviews have yielded inadequate and conflicting data concerning the ideal treatment of LAH [4,5,6]. This article provides a systematic review of LAH, addresses current controversies, and pro-. Poses an algorithmic approach to LAH treatment. All English language LAH publications for the years 1973 to 2010 which addressed the epidemiology, biochemical association, etiology, pathogenesis, clinical presentation, preoperative imaging studies, intraoperative parathyroid hormone monitoring (IOPTH), surgical management (parathyroidectomy) and surveillance were collected and analyzed. The literature search was performed utilizing PubMed with the following keywords; “lithium” “hypercalcemia” “hyperparathyroidism” “sestamibi” “IOPTH” “parathyroidectomy” “medical management”and “cinacalcet”
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