Hypoparathyroidism Post Thyroidectomy: Prevention, Evaluation, Management, and Application of Recent Guidelines

Background: Postsurgical hypoparathyroidism (HypoPT) accounts for ∼75% of all HypoPT cases. It is recognized that this condition is largely preventable. Several studies have identified risk factors increasing the risk of developing postsurgical HypoPT, including patient-related factors, surgical factors, and, in some studies, presurgical factors. This narrative review highlights evidence-based guidelines for postsurgical HypoPT and provides strategies for its prevention, diagnosis, and management. Methods: We searched PubMed, Embase, Google Scholar, and the Cochrane Library from inception through December 2025. We included studies that examined the definition, diagnosis, prevalence, risk factors, management, long-term complications, and treatment outcomes of postsurgical HypoPT. Results: This review outlines strategies for identifying individuals at risk of developing postsurgical HypoPT, with the goal of minimizing these risks and using evidence-based approaches to accurately diagnose and effectively manage these patients. Historically, management of postsurgical HypoPT beyond the first 72 hours relied on calcium supplements with active vitamin D, which remains the first-line therapy in current practice. Parathyroid hormone (PTH) replacement has emerged as an option for individuals who do not respond to conventional therapy. More recently, a long-acting PTH molecule, palopegteriparatide, has been approved by the Food and Drug Administration for the management of HypoPT. This molecule has a 60-hour half-life and has demonstrated the ability to maintain normal serum calcium levels, lower urine calcium, lower serum phosphorus, and reduce the need for calcium and active vitamin D supplements. It has also demonstrated a positive impact on quality of life. Post hoc data from the phase 3 trial comparing palopegteriparatide with placebo demonstrated improvements in renal function with palopegteriparatide and cessation of conventional therapy in patients with HypoPT. Conclusions: Postsurgical HypoPT remains a significant complication of thyroid surgery; however, its risk can be mitigated by careful preoperative assessment and surgical technique. While conventional therapy continues to be the mainstay of treatment, the advent of PTH replacement therapies offers promising alternatives for patients with refractory HypoPT.