Surgical Science, 2011, 2, 468-475
doi:10.4236/ss.2011.210103 Published Online December 2011 (http://www.SciRP.org/journal/ss)
Lithium Associated Hyperparathyroidism: An Evidence
Based Surgical Approach
Umashankar K. Ballehaninna1,2, Steven M. Nguyen3, Ronald S. Chamberlain1,3,4
1Department o f S urg e ry, Saint Barnabas Medical Center, Livingston, USA
2Department o f S urg e ry, Maimonides Medical Center, Brooklyn, USA
3Department o f S urg e ry, University of Medicine and Dentistry of New Jersey, Newark, USA
4Saint George’s University, School of Medi ci ne , West Indies, Grenada
Received May 17, 2011; revised August 15, 2011; accepted October 17, 2011
Abstract
Background: Long-term lithium use in psychiatric patients may lead to lithium associated hyperparathyroi-
dism (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 pub-
lications addressing etiology and clinical management issues concerning LAH were critically analyzed. Re-
sults: 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 in-
cludes 10 patients (5%) treated medically and 170 patients (88%) who underwent parathyroidectomy. No de-
tails 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 bio-
chemical changes in nearly all patients (90% - 97%) in the early post-operative period, but recurrent hyper-
parathyroidism occurred in 8% - 42% of patients. Conclusion: LAH is an under appreciated and poorly un-
derstood endocrine disorder. LAH has a higher incidence of multiglandular disease and bilateral neck explo-
ration is mandatory in majority for disease control. Nonsurgical approaches may be useful in select patients
on short-term lithium therapy.
Keywords: Lithium, Hypercalcemia, Hyperparathyroidism, Sestamibi Intra-Operative Parathyroid Hormone
(IOPTH) Monitoring, Parathyroidectomy, Medical Management
1. Introduction
Lithium Carbonate (Li+) is the preferred and most effi-
cacious therapy for acute treatment and maintenance the-
rapy for bipolar depressive disorder, and is a useful ad-
junct in unipolar depression [1,2]. Long-term lithium the-
rapy is associated with multiple endocrine and metabolic
alterations such as hyperthyroidism, hypothyroidism, re-
duced bone mineral density (BMD), osteopenia, as well
as several gastrointestinal (nausea, constipation), cardio-
vascular (bradyarrythmias), renal (nephrocalcinosis, re-
duced glomerular filtration rate (GFR), polyuria, nephro-
genic diabetes insipidus) and psychosomatic adverse eff-
ects (weakness, fatigue, depression). Chronic lithium the-
rapy is also associated with hyperparathyroidism (LAH)
characterized by hypercalcemia, hypermagnesemia, re-
duced 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 in-
adequate and conflicting data concerning the ideal treat-
ment of LAH [4-6]. This article provides a systematic
review of LAH, addresses current controversies, and pro-

U. K BALLEHANINNA ET AL.469
poses an algorithmic approach to LAH treatment.
1.1. Methods/Materials
All English language LAH publications for the years
1973 to 2010 which addressed the epidemiology, bioche-
mical association, etiology, pathogenesis, clinical presen-
tation, preoperative imaging studies, intraoperative para-
thyroid hormone monitoring (IOPTH), surgical manage-
ment (parathyroidectomy) and surveillance were collected
and analyzed. The literature search was performed utiliz-
ing PubMed with the following keywords; “lithium” “hy-
percalcemia” “hyperparathyroidism” “sestamibi” “IOPTH”
“parathyroidectomy” “medical management”and “ci-
nacalcet”.
1.2. Results
Lithium use is associated with an increased incidence of
hyperparathyroidism (4.3% - 6.3%) and a female prepon-
derance (F: M 4:1) compared to primary hyperparathy-
roidism in the general population (0.5% - 1% and F: M
3:1). A total of 194 cases of LAH have been reported in
English language literature of which 170 patients (88%)
were treated by surgical resection (parathyroidectomy), 10
patients (5%) were managed medically and no details are
available for 14 patients (7%). (Tables 1 and 2) Among
those who had parathyroidectomy, 104 patients (61%) had
adenomatous disease and 66 patients (39%) had multi-
gland parathyroid hyperplasia compared to primary hy-
perparathyroidism (PHPT) in the general population in
whom single adenoma is seen in 85% and multigland hy-
perplasia is identified in 15%. Among 170 LAH patients
undergoing parathyroidectomy, preoperative localization
studies (sestamibi scan, neck ultrasound, CT scan) were
utilized in only 22 patients (14%) and IOPTH monitoring
was reported in only 3 studies (32 patients, 19%).
Bilateral neck exploration was the most common sur-
gical approach utilized and was utilized in 162 patients
(95%), whereas focused neck exploration was performed
Table 1. Published studies on the surgical management of lithium associated hyperparathyroidism (1973-2010).
Adenoma
Author, Year Total (N =) Surgically Treated
(N =) (%) Single
(N =) (%)
Double
(N =) (%)
Four gland hyperplasia
(N =) (%)
Remarks (Surgical approach,
BNE, IOPTH monitoring)
Garfinkel et al. [10], 1973 1 1 (100%) 1 (100%)- - First reported case, BNE
Ananth et al. [20], 1983 3 2 (67%) 2 (67%)- - BNE, 1 patient-details-NA
Stancer et al. [15], 1989 8 3 (37.5%) 1 (12.5%)- 2 (25%) BNE, 5 patients-details-NA
Nordenstrom et al. [19], 1992 6 6 (100%) 1 (17%)- 5 (83%) BNE
Bendz et al. [8], 1996 8 8 (100%) 3 (37.5%)2 (25%) 3 (37.5%) Point prevalence of LAH-3.6%
McHenry et al. [3], 1996 25 17 (68%) 12 (48%)- 5 (20%) BNE, 8 patients-details-NA
Wolf et al. [21], 1997 1 1 (100%) - - 1 (100%) BNE
deCelis et al. [22]. 1998 1 1 (100%) 1 (100%)- - BNE
Abdullah et al. [17], 1999 11 11 (100%) 6 (55%)3 (27%) 2 (18%) BNE, 1 recurrence
Awad et al. [5], 1999 15 15 (100%) 11 (73%)3 (20%) 1 (7%) BNE
Hundley et al. [18], 2005 12 12 (100%) 6 (50%)3 (25%) 3 (25%) IOPTH monitoring
Carchman et al. [16], 2008 16 16 (100%) 12 (75%)- 4 (25%) IOPTH monitoring, 8 patients
had focused neck exploration
Rizwan et al. [27], 2009 1 1 (100%) - - 1 (100%) BNE
Szalat et al. [12], 2008 4 4 (100%) 1 (25%)2 (50%) 1 (25%) 75% MGH, IOPTH monitoring
Jarhult et al. [14], 2010 71 71 (100%) 32 (45%)2 (3%) 37 (52%) BNE, 42% had recurrence
Current study, 2010 1 1 (100%) - - 1 (100%) IOPTH, BNE
Overall 184*, + 170 (92%) 89 (52%)15 (7%) 66 (39%)
Multigland (adenomas and
hyperplasia seen in 46%), *No
details available for 14 (7%)
patients, +10 patients managed
medically see table 2.
Abbreviations: N, number of patients; BNE, bilateral neck exploration; MGH, Multiglandular hyperplasia; IOPTH, intraoperative parathyroid hormone moni-
toring; LAH, lithium associated hyperparathyroidism; NA, not available. Note: Published studies on the surgical management of LAH document that a single
adenoma is the most common LAH associated pathology (61%). However, increased prevalence of double adenomas (7%) and multigland hyperplasia (39%)
suggests that bilateral neck exploration is necessary in the majority of LAH patients (96%). Pre-operative localization studies and IOPTH monitoring may have
utility in LAH patients, however data on their value is limited (N = 22, 33 respectively).

U. K BALLEHANINNA ET AL. 470
Table 2. Published studies on the medical management of lithium associated hyperparathyroidism (1973-2010).
Author, Year N = Management
Gama et al. [3], 1999 1 Resolution of LAH after lithium was discontinued
Sloand et al. [23], 2006 2 Modest response while lithium was continued in one patient
Khandawala et al. [24], 2006 1 Resolution of LAH after lithium was discontinued
Rifai et al. [25], 2006 1 Discontinuation of Li+, normocalcemia achieved by cinacalcet
Duggal et al. [26], 2007 1 Resolution of LAH after lithium was discontinued
Gregoor et al. [34], 2007 3 Cinacalcet therapy ameliorated LAH
Szalat et al. [12], 2009 1 Postoperative recurrence—hypercalcemia corrected with cinacalcet, however elevated PTH persisted.
Abbreviations: LAH, lithium associated hyperparathyroidism, Li+, Lithium, PTH, parathyroid hormone. Note: Medical management (withdrawal of lithium
and/or use of cinacalcet) has been successfully used to treat a small number of LAH patients.
in 8 (5%) patients. The latter approach was utilized signi-
ficantly less often in LAH when compared to PHPT pa-
tients in whom the published unilateral focused neck ex-
ploration rate is 80% - 95% [7]. This change likely re-
flects the increased incidence of four-gland hyperplasia
in LAH. Parathyroidectomy normalized LAH associated
biochemical changes in nearly all patients (67% - 100%)
in the early post-operative period, however at a median
long-term follow-up of 6.3 years 8% - 42% patients ex-
perienced recurrence.
2. Case Review
A 64 year-old female with a past medical history of type
II diabetes mellitus, hypertension, hypercholesterolemia,
and bipolar depression was referred for surgical evalua-
tion due to persistent hypercalcemia. She had been tre-
ated with lithium (300 mg BID) for four years. Over the
prior three years, the patient had mild elevations of her
serum calcium level (normal range; 10 - 11 mg/dL) which
rose to 11.7 mg/dL and 12.3 mg/dL over a two months
duration. Symptomatically she complained of decreased
memory and mental clarity. Her diabetes was well con-
trolled (hemoglobin A1C level of 6%) with no evidence
of retinopathy or nephropathy. A sestamibi parathyroid
scan localized a parathyroid adenoma at the mid pole of
the left lobe of the thyroid gland. The patient was sched-
uled for a PTH directed left parathyroidectomy under
local anesthesia. Pre-operative PTH level was 147 pg/ml
(normal range; 10 - 55 pg/ml). At exploration a large cy-
stic structure was identified on the anterior surface of the
left lower thyroid lobe which obscured the surgical field.
The procedure was converted to general anesthesia and
exploration was expanded to the upper pole of the thy-
roid where an enlarged left superior parathyroid gland
was identified and removed. On pathologic review the
gland was hypercellular and weighed 286 mg. A post-
excision intact PTH level measured 15 minutes after ex-
cision remained high (89 pg/ml), and a four-gland ex-
ploration of the neck was performed. Enlarged right su-
perior (866 mg) and inferior parathyroid glands (256 mg)
were identified and removed. The left inferior parathy-
roid was partially resected and intraoperative pathologic
evaluation identified this gland as also hypercellular. The
remaining portion of the left inferior parathyroid was
autotransplanted into the left sternocleidomastoid muscle.
The post-operative course was uncomplicated and the
patient was discharged home on day 2 with a serum cal-
cium level of 9.1 mg/dl and a PTH level of 15.8 pg/mL.
3. Discussion
A causal association between chronic lithium therapy
and hyperparathyroidism has been conclusively demon-
strated. As noted earlier, patients on long-term lithium
therapy have a 4 - 6 fold increased incidence of hyper-
parathyroidism compared to the general population [5,7].
Bendz et al. identified a 2.7% increased point prevalence
of hyperparathyroidism among 124 patients on long-term
lithium therapy (>15 years), while Mallette et al. revi-
ewed studies involving 309 patients on chronic lithium
therapy and identified 37 patients (12%) with hypercal-
cemia and 18 patients (16%) with elevated PTH levels
[8-10]. McHenry et al. have reported that 80% of pa-
tients treated with lithium for 6 to 24 months experience
a 10% increase in serum calcium levels. Christiansen et
al. re- ported that both serum calcium and PTH levels
increased by 30% in the same population, and several
other authors have also reported a 10% - 60% increased
prevalence of hypercalcemia and hyperparathyroidism in
patients taking lithium [11-14].
LAH is associated with characteristic biochemical
changes consisting of an elevated serum levels of calci-
um, magnesium and parathyroid hormone and decreased
urinary calcium and cyclic adenosine monophosphate
(CAMP) levels. These changes are similar to familial
hypocalciuric hypercalcemia (FHH), but distinct from
PHPT in which urinary calcium excretion is increased

U. K BALLEHANINNA ET AL.471
[15]. A large number of mechanisms have been proposed
to account for the biochemical changes seen in LAH.
(Table 3) To briefly summarize, lithium competitively
antagonizes calcium sensing receptors (CaSR) and raises
the threshold of serum calcium necessary to inhibit PTH
secretion. This action not only increases parathyroid hor-
mone secretion, but also exerts a multitude of systemic
effects on the parathyroid glands, renal tubules and bone
metabolism resulting in parathyroid gland hyperplasia
and biochemical changes. Lithium is also known to ac-
centuate adenoma formation by increasing PTH gene
transcription, which may unmask hyperparathyroidism in
patients with sub-clinical pre-existing adenomas once
lithium is initiated.
As a consequence of the aforementioned systemic ef-
fects, it seems reasonable to conclude that lithium use
should be associated with multiglandular parathyroid hy-
perplasia. However in most series, a solitary parathyroid
adenoma was the most common LAH associated pathol-
ogy. Awad et al. reported parathyroid adenomas in 14
out of 15 patients (93%) with LAH, and Carchman et al.
identified adenomas in 12 out of 16 LAH patients (75%)
[5,16]. Similarly, in a series of 12 LAH patients, Hun-
dley et al. noted parathyroid adenomas in 9 patients (75%),
while Bendz et al. reported adenoma in 72.5% of LAH
patients (5 out of 8) [8,18]. Of note however, many au-
thors have also described a higher incidence of multi-
glandular hyperplasia. Nordenstrom et al. identified mul-
tiglandular hyperplasia (MGH) in 83% of LAH patients
(5 out of 6) [19]. Likewise, Jarhult et al. studied 71 pa-
tients with LAH and reported MGH in 37 patients (52%)
[14]. Table 1 summarizes all reported LAH cases and
demonstrates that parathyroid adenoma was the most
common pathology identified in 104 out of 170 patients
(61%) following parathyroidectomy [3,5,8,23-26]. (Ta-
ble 1) In comparison, PHPT is associated with a single
adenoma 85%, multigland hyperplasia (MGH) 15% and
parathyroid carcinoma in 1% of patients [7]. It is impor-
tant to point out that there is also an increased incidence
rate of multigland hyperplasia (MGH) in LAH (39%, 66
of 170 patients) compared to the general population with
PHPT (15%). This increased MGH incidence is likely
attributable to the systemic action of lithium, and as a
result may effect interpretation of localization studies
(increased false negative rate, poor sensitivity) and sur-
gical planning (increased need of bilateral neck explora-
tion) [3,4,6,18].
The initial management of LAH is medical intervene-
tion which includes discontinuation of lithium or alterna-
tive treatment such as atypical antipsychotics and cal-
cimimmetics. (Table 2) Data relating to the efficacy of
LAH medical management is available for only 10 of
194 reported LAH patients (5%). As such it is difficult to
make any meaningful conclusions [12,23-26,34]. In
many LAH patients, discontinuation of lithium carbonate
is not medically feasible due to increased propensity of
relapse [35,36]. Although serum Ca2+ and PTH levels
tend to normalize within 4 - 6 weeks after lithium dis-
continuation, this change is mostly seen in patients re-
ceiving lithium for a relatively short-term defined as 5 -
10 years, or in those with only mild hypercalcemia [4].
Khandawala et al. reported on one patient who was tak-
ing lithium for 5 years, discontinuation of Li+ resulted in
normocalcemia and a normal PTH level which was
maintained at 5 months follow-up [24]. Dugal et al. re-
ported on a single patient who had been on lithium ther-
apy for 10 years, in whom discontinuation of lithium and
simultaneous saline diuresis with furosemide also achi-
Table 3. Proposed mechanisms of action responsible for Lithium associated hyperparathyroidism (LAH).
Mechanism of action Explanatation
Antagonism of cations [28,29] Li+ competitively antagonizes cations at calcium receptor at several locations—kidney, bone and
parathyroid gland—causing acute hypercalcemia and hyper-magnesemia
↑ Set point or reset “calci-stat”
[4,12,30, 31]
Li+ antagonizes calcium sensing receptor (CASR) causing a shift in inhibitory set point for PTH
secretion, which then requires a higher levels of calcium level to block PTH secretion. This results in
an overproduction of PTH despite elevated serum calcium levels
Mitogenic action [16,32,33]
Li+ exacerbates a pre-existing adenoma or PHPT—this occurs especially in patients presenting with
psychiatric symptoms—the lithium therapy worsens hypercalcemia by promoting PTH overproduc-
tion. Nearly 55% of LAH have parathyroid adenomas (single or double).
↑ Parathyroid volume and parathyroid
hyperplasia [2,5,11]
LAH is associated with multiglandular hyperplasia in 25% - 55% cases (Table 1) compared to 15%
in PHPT, which is attributed to direct stimulation of parathyroid gland by lithium. In patients on
chronic lithium therapy neck ultrasound demonstrates increased parathyroid gland volume.
Mechanism:
1) Inhibits inosital monophosphate (IMP) which regulates intracellular calcium exposure to nuclear
CASR in PTH cells, thus altering the set point to turn-off PTH gene transcription.
2) Li+ inhibits glycogen synthase kinase-3b (GSK-3b) responsible for inhibition of PTH gene tran-
scription, thereby leading to overproduction of PTH.
Abbreviations: PHPT-primary hyperparathyroidism; PTH, parathyroid hormone; Li+, lithium; CASR, calcium sensing receptor; IMP, inosital monophosphate;
GSK-3b, glycogen synthase kinase-3b. Note: Several different mechanisms have been proposed by which lithium may cause hypercalcemia, ↑ PTH levels, ↑
magnesium and ↓ urinary calcium levels.

U. K BALLEHANINNA ET AL. 472
eved normocalcemia [26]. In contrast, drug withdrawal
from patients on chronic lithium therapy (>10 years), has
a lower rate of hypercalcemia resolution [4]. Carchman
et al. noted that even after discontinuation of lithium for
more than 5 months, 8 out of 16 patients on chronic lith-
ium therapy experienced persistent hypercalcemia [16].
In LAH patients who have mild hypercalcemia or were
asymptomatic, alternative medical therapy such as val-
proate, carabamazepine or atypical antipsychotics (rise-
peridone) may be treatment alternatives, however at pre-
sent there is very limited data to assess their efficacy in
LAH patients [2,4].
Recently, a new class of drugs (calcimimmetics, ex-
ample: cinacalcet) has been successfully used to treat
LAH with or without discontinuation of lithium [34].
(Table 3) Calcimimmetics activate calcium-sensing re-
ceptors (blocked by lithium) which in turn reduce PTH
secretion and prevent parathyroid hyperplasia. To date, a
biochemical remission was achieved in 6 cases using
cinacalcet among patients on chronic lithium therapy [12,
23,25,34]. Gregoor et al. reported resolution of LAH in 3
patients using cinacalcet while lithium was continued
[34]. Szalat et al. used cinacalcet in an LAH patient who
had a post-operative recurrence of hyperparathyroidism
and reported resolution of hypercalcemia despite persis-
tently elevated PTH levels [12]. Although above results
are intriguing, the consistently reproducible results of
parathyroidectomy have made surgical therapy the main-
stay of LAH management, particularly among sympto-
matic patients with moderate to severe hypercalcemia,
and those in whom discontinuation of Li+ is not feasible
or has failed [4].
The most common indication for parathyroidectomy in
LAH patients include worsening psychosomatic (50% -
60%) (fatigue, weakness, decreased concentration, short-
term memory loss, depression), bone (30% - 40%) (bone
pain, reduce bone mineral density, osteopenia or osteo-
porosis), gastrointestinal symptoms (20% - 30%) (con-
stipation, nausea or pancreatitis), cardiac dysrhythmias
and renal symptoms (1% - 5%) (decreased GFR, decreased
creatinine clearance or nephrocalcinosis) [3,5,12,15,18].
Today, preoperative localization studies (ultrasound of
neck, sestamibi scan and computerized tomography (CT)
scan of neck) have been routinely incorporated into the
management algorithm of PHPT patients, and resulted in
the near universal use of focused neck exploration (90%
- 95%) for this group. However, there is a paucity of data
supporting the utility of preoperative localization studies
in LAH patients. Among 195 LAH patients who under-
went parathyroidectomy, preoperative localization stu-
dies were utilized in only 22 patients (13%). In the larg-
est series involving 18 patients, Carchman et al. used se-
stamibi scan or ultrasound in 16 patients (94%). Imaging
studies predicted a single adenoma in 10 patients, 2 (20%)
of which had MGH at exploration [19]. In the same study,
pre-operative localization studies identified MGH in 4
patients, however 2 of these patients subsequently were
found to have only a single adenoma at exploration. Li-
mited or focused neck exploration was possible in only 8
of 16 patients (50%) aided by both pre-operative loca-
lization studies and IOPTH monitoring. Szalat et al. have
also reported using preoperative neck ultrasound and
parathyroid scan which identified solitary uptake in 3 of
4 cases. However, at exploration IOPTH testing failed to
return to baseline or decrease by >50% (positive re-
sponse), and all patients required bilateral neck explora-
tion (BNE) [12]. Despite the small number of patients
included in these studies, they nevertheless highlight the
poor sensitivity and limited utility of pre-operative loca-
lization studies for precise localization of pathogically
enlarged parathyroid glands in LAH and in planning sur-
gical approach [6].
Parathyroidectomy is the main stay of treatment for
LAH patients. Given the reported higher incidence of
multiglandular hyperplasia (39%) and double adenomas
(7%), it is not surprising that bilateral neck exploration
(BNE) is the most commonly reported surgical approach
in LAH. Among 170 patients with LAH, BNE was used
in 162 patients (95%), whereas focused neck exploration
was performed in only 8 patients (5%). In the largest
reported LAH series, Jarhult et al. utilized BNE in all but
2 of 71 patients who underwent parathyroidectomy [14].
As noted earlier, intraoperative parathyroid hormone
monitoring (IOPTH) has been extensively validated in
patients with PHPT, and prompted more limited surgical
exploration [7]. To date, only 3 studies involving LAH
patients (N = 32) have assessed the usefulness of IOPTH
monitoring [12,18,19]. Hundley et al. utilized IOPTH
monitoring in 12 patients with LAH, of which 6 patients
underwent MGH resection prompted by IOPTH moni-
toring [18]. In a study of 16 patients, Carchman et al.
performed focused parathyroidectomy in 8 patients,
while 8 patients underwent BNE guided by IOPTH mo-
nitoring [19]. Of note, these authors were able to perform
a limited surgical exploration in 50% of LAH patients,
compared to a 5% rate in other LAH series [12,14].
Parathyroidectomy results in biochemical remission
leading to normocalcemia and normal PTH levels in the
immediate post-operative period and improves psycho-
somatic symptoms in 90% - 97% of LAH patients. Awad
et al. observed eucalcemia in 15 out of 16 patients who
had parathyroidectomy for LAH; however, one patient
subsequently developed recurrence at 2 years and under-
went neck re-exploration with removal of an additional
parathyroid adenoma [5]. At a median follow-up of 6
months (5 - 50 months range), Carchman et al. noted that

U. K BALLEHANINNA ET AL.473
all patients were eucalcemic, however 2 patients had
mild PTH elevation [19]. In contrast, Jarhult et al. re-
ported that among 71 LAH patients who underwent pa-
rathyroidectomy, 30 patients (42%) had persistent or
recurrent hyperparathyroidism at a median follow-up of
6.3 years [14]. In this series, six out of 30 patients with
persistent/recurrent HPT underwent surgical re-explora-
tion but only 2 patients were cured of hypercalcemia, one
had permanent hypocalcaemia.
4. An Evidence Based Algorithm for the
Management of LAH
Knowledge of the higher prevalence of hyperparathyroi-
dism in chronic lithium users coupled with published
data on the medical and surgical treatment of LAH pro-
vides a basis for developing an algorithmic approach for
the treatment of LAH. (Figure 1) Serum calcium levels
should be drawn before initiating lithium therapy (to rule-
Figure 1. An evidence based algorithm for the management of lithium associated hyperparathyroidism. Abbreviations: S.
Ca2+, Serum calcium; S. Mg2+, Serum magnesium; S. PTH-serum parathormone; CVS-cardiovascular system; GI-gastro-
intestinal system; 4D-CT, 4-dimensional computed tomography; SPECT), Single Photon Emission Computed Tomography
scan; IOPTH, Intra-operative parathormone monitoring; BNE, bilateral neck exploration.

U. K BALLEHANINNA ET AL. 474
out pre-existent primary HPT) and monitored within 4 -
6 weeks of beginning lithium therapy, and every 3 months
thereafter. Serum PTH levels should be measured when-
ever hypercalcemia is identified. A confirmatory diagno-
sis of LAH necessitates ruling-out other causes of HPT.
Asymptomatic patients with mild to moderate hypercal-
cemia may be monitored at regular intervals. The Natio-
nal Institute of Health (NIH) guidelines for the treatment
of PHPT are also useful in LAH patients in regards to pa-
tient selection for parathyroidectomy [37]. (Figure 1)
When medically feasible lithium should be discontinued
or alternative therapy substituted (valproate, carbamaze-
pine or atypical antipsychotics) in selected LAH patients.
Cinacalcet hydrochloride, a calcimimmetic agent, may
have modest efficacy in treating LAH, and be beneficial
to patients in whom discontinuation of lithium is not me-
dically feasible or when surgery is contraindicated. In the
vast majority of symptomatic patients, and in those in
whom either discontinuation of lithium is not possible or
when alternative therapy has failed to correct hypercal-
cemia, parathyroidectomy is required. While preopera-
tive localization studies may provide useful information
regarding the number and location of enlarged parathy-
roid glands, the increased incidence of multiglandular
disease in LAH, as well as a higher risk of recurrent or
persistent HPT, mandates meticulous surgical explora-
tion to visualize and remove all pathologically enlarged
gland(s). Whereas a single parathyroid adenoma is found
in the majority (61%) of LAH patients, limited or fo-
cused surgical exploration may be attempted when pre-
operative localization studies suggest feasibility, but must
be further confirmed with IOPTH monitoring. A very
high incidence of persistent and recurrent disease in
LAH patients necessitates long-term follow-up and strict
surveillance (Figure 1).
In summary, lithium use in psychiatric patients may be
associated with hypercalcemia and elevated PTH levels
referred to as lithium associated hyperparathyroidism
(LAH). An algorithmic approach and strict post-opera-
tive surveillance protocols may improve treatment suc-
cess and identify recurrent or persistent disease (Figure
1).
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