Best practice recommendations for the diagnosis and management of hypoparathyroidism

Aliya A Khan; Dalal S Ali; John P Bilezikian; Sigridur Björnsdottir; Michael T Collins; Natalie E Cusano; Peter R Ebeling; Ghada El Haj Fuleihan; Seiji Fukumoto; Andrea Giustina; Stephanie M Kaiser; Christian A Koch; Tayyab Khan; Patty Keating; Jian-Min Liu; Christos S Mantzoros; Michael Mannstadt; Ambrish Mithal; Nancy D Perrier; Michele Rayes; René Rizzoli; Yumie Rhee; Mishaela R Rubin; Kelly L Roszko; Muhammad Shrayyef; Dolores M Shoback; Tanja Sikjær; Heide Siggelkow; Jad Sfeir; Rajesh Thakker; Stan Van Uum; Karen K Winer; Dilek Gogas Yavuz; Bulent O Yildiz; Hajar Abu Alrob; Maria Luisa Brandi

doi:10.1016/j.metabol.2025.156335

Best practice recommendations for the diagnosis and management of hypoparathyroidism

Metabolism. 2025 Jun 26:156335. doi: 10.1016/j.metabol.2025.156335. Online ahead of print.

Authors

Aliya A Khan¹, Dalal S Ali², John P Bilezikian³, Sigridur Björnsdottir⁴, Michael T Collins⁵, Natalie E Cusano⁶, Peter R Ebeling⁷, Ghada El Haj Fuleihan⁸, Seiji Fukumoto⁹, Andrea Giustina¹⁰, Stephanie M Kaiser¹¹, Christian A Koch¹², Tayyab Khan¹³, Patty Keating¹⁴, Jian-Min Liu¹⁵, Christos S Mantzoros¹⁶, Michael Mannstadt¹⁷, Ambrish Mithal¹⁸, Nancy D Perrier¹⁹, Michele Rayes¹⁴, René Rizzoli²⁰, Yumie Rhee²¹, Mishaela R Rubin²², Kelly L Roszko²³, Muhammad Shrayyef²⁴, Dolores M Shoback²⁵, Tanja Sikjær²⁶, Heide Siggelkow²⁷, Jad Sfeir²⁸, Rajesh Thakker²⁹, Stan Van Uum³⁰, Karen K Winer³¹, Dilek Gogas Yavuz³², Bulent O Yildiz³³, Hajar Abu Alrob³⁴, Maria Luisa Brandi³⁵

Affiliations

¹ Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada. Electronic address: draliyakhan@gmail.com.
² Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada.
³ Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, United States.
⁴ Department of Medicine, Heilsuklasinn, Reykjavik, Iceland.
⁵ Senior Clinical Advisory, National Institute of Dental and Craniofacial Research, Bethesda, MD, United States.
⁶ Zucker School of Medicine at Hofstra/Northwell, New York, United States.
⁷ Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Australia.
⁸ Department of Internal Medicine, Division of Endocrinology, Calcium Metabolism and Osteoporosis Program, WHO Collaborating Center for Metabolic Bone Disorders, American University of Beirut Medical Center, Beirut, Lebanon.
⁹ Department of Internal Medicine, Tamaki-Aozora Hospital, Tokushima, Japan.
¹⁰ Institute of Endocrine and Metabolic Sciences, San Raffaele Vita-Salute University, San Raffaele IRCCS Hospital, Via Olgettina, Milan, Italy.
¹¹ Department of Medicine, Dalhousie University, Halifax, NS, Canada.
¹² The University of Florida, Jacksonville, Department of Medicine, United States.
¹³ St. Joseph's Health Care London, London, Canada; Department of Medicine, Western University, London, ON, Canada.
¹⁴ HypoPARAthyroidism Association, United States.
¹⁵ Department of Endocrine and Metabolic Disease, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
¹⁶ Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States; Boston VA Healthcare System, Harvard Medical School, Boston, MA, United States.
¹⁷ Endocrine Unit, Massachusetts General Hospital, Boston, United States.
¹⁸ Institute of Diabetes and Endocrinology, Max Healthcare, New Delhi, India.
¹⁹ Department of Surgical Oncology, Section of Surgical Endocrinology, University of Texas MD Anderson Cancer Center, Houston, TX, United States.
²⁰ Professor of Medicine at the University Hospitals of Geneva, Geneva, Switzerland.
²¹ Department of Internal Medicine, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.
²² Department of Endocrinology, Columbia University Irving Medical Center, NY, New York, United States.
²³ National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, United States.
²⁴ Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
²⁵ Endocrine Research Unit, San Francisco Veterans Affairs Medical Center, University of California, San Francisco, California, United States.
²⁶ Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark; Department of Internal Medicine, Horsens Regional Hospital, Horsens, Denmark.
²⁷ Research and Development, Department of Trauma, Orthopedics and Reconstructive Surgery, University of Göttingen, Göttingen, Germany; MVZ Endokrinologikum Göttingen, Göttingen, Germany.
²⁸ Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, United States.
²⁹ Department of Medicine, Churchill Hospital, University of Oxford, Oxford, United Kingdom; NIHR Biomedical Research Centre, Oxford University Hospitals Trust, Oxford, United Kingdom; Centre for Endocrinology, Metabolism, William Harvey Research Institute, Barts, The London School of Medicine, Queen Mary University of London, London, UK.
³⁰ Department of Medicine, Western University, London, ON, Canada.
³¹ Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), NIH, Bethesda, MD, United States.
³² Marmara University School of Medicine, Section of Endocrinology and Metabolism, Istanbul, Turkey.
³³ Division of Endocrinology and Metabolism, Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey.
³⁴ Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada.
³⁵ F.I.R.M.O. Italian Foundation for the Research on Bone Diseases, Florence, Italy; Vita-Salute San Raffaele University, 20132 Milan, Italy.

PMID: 40581321
DOI: 10.1016/j.metabol.2025.156335

Abstract

Background: Hypoparathyroidism (HypoPT) is characterized by low serum calcium due to insufficient parathyroid hormone (PTH). This manuscript builds upon the 2022 international HypoPT guidelines and three systematic reviews, which have been further informed by updated narrative reviews and expert consensus. This paper presents current best practice consensus recommendations for the diagnosis and management of HypoPT.

Methods: An International Panel of Experts updated the previous systematic reviews (SR's), conducted narrative reviews, developed, and subsequently approved these best practice recommendations at the Parathyroid Summit, held as a pre-Endocrine Society meeting in May 2024 (Boston, USA).

Results: Diagnostic criteria for chronic HypoPT require hypocalcemia with inappropriately normal or low PTH levels. Conventional therapy is recommended as first line therapy and includes calcium supplementation, active vitamin D, correction of vitamin D inadequacy and correction of abnormalities in serum magnesium. Monitoring is required to achieve optimal serum calcium while avoiding hyperphosphatemia, hypercalciuria and declines in renal function. Assessment of HypoPT complications is required including skeletal health assessment in postmenopausal women and men over the age of 50 years. Specific strategies are provided for managing HypoPT during pregnancy and lactation as well as in children. PTH replacement with palopegteriparatide has been approved and is an important therapeutic option, especially when conventional therapy is inadequate or not tolerated.

Conclusion: These best practice recommendations provide a framework for HypoPT diagnosis and management, emphasizing individualized care, role of DNA analysis in the diagnosis of nonsurgical HypoPT, and role of PTH or PTH analogue therapy as appropriate. They complement the 2022 international guidelines and incorporate updated therapeutic recommendations from the past 3 years including the positioning of the newly approved molecule palopegteriparatide based on recent clinical trial data and expert consensus.

Keywords: Best practice recommendations; Expert consensus; Hypoparathyroidism.

Publication types

Review