What are the common treatments for hyperparathyroidism (Primary Hyperparathyroidism)?

From the Guidelines

The primary treatment for hyperparathyroidism is surgical removal of the affected parathyroid gland(s), known as parathyroidectomy, which is typically indicated even in asymptomatic patients due to the potential negative effects of long-term hypercalcemia. This approach is supported by the most recent evidence from the Journal of the American College of Radiology 1, which highlights the importance of surgical excision of the abnormally functioning parathyroid tissue. There are two accepted curative operative strategies for primary hyperparathyroidism (PHPT): bilateral neck exploration (BNE) and minimally invasive parathyroidectomy (MIP).

Key Considerations for Treatment

• BNE is a bilateral operation where all parathyroid glands are identified and examined, and the diseased glands are resected 1.
• MIP is a unilateral operation that utilizes limited dissection for targeted removal of only the affected gland, requiring confident and precise preoperative localization of a single parathyroid adenoma 1.
• The choice between BNE and MIP depends on factors such as the presence of a single adenoma, multigland disease, and the accuracy of preoperative imaging 1.

Importance of Preoperative Imaging

• Preoperative imaging plays a crucial role in localizing the abnormally functioning gland or glands with high accuracy and confidence to facilitate targeted curative surgery 1.
• Imaging has no utility in confirming or excluding the diagnosis of PHPT but is essential in the reoperative setting to localize a target parathyroid lesion and identify postoperative changes from previous parathyroid explorations 1.

Postoperative Care and Follow-Up

• Persistent PHPT is defined as failure to achieve normocalcemia within 6 months of initial parathyroidectomy, whereas recurrent PHPT is defined as hypercalcemia occurring after a normocalcemic interval of 6 months or more after parathyroidectomy 1.
• Regular monitoring of calcium, phosphate, and parathyroid hormone levels is essential to assess treatment effectiveness and adjust therapy accordingly.

From the FDA Drug Label

Cinacalcet tablets are indicated for the treatment of secondary hyperparathyroidism (HPT) in adult patients with chronic kidney disease (CKD) on dialysis [see Clinical Studies (14. 1)]. Cinacalcet tablets are indicated for the treatment of hypercalcemia in adult patients with Parathyroid Carcinoma [see Clinical Studies(14.2)]. Cinacalcet tablets are indicated for the treatment of hypercalcemia in adult patients with primary HPT for whom parathyroidectomy would be indicated on the basis of serum calcium levels, but who are unable to undergo parathyroidectomy [see Clinical Studies (14.3)].

The common treatment for hyperparathyroidism is cinacalcet. The dosage and administration vary depending on the type of hyperparathyroidism:

• Secondary hyperparathyroidism: The recommended starting oral dose is 30 mg once daily, titrated every 2 to 4 weeks to target iPTH levels of 150 to 300 pg/mL.
• Parathyroid carcinoma and primary hyperparathyroidism: The recommended starting oral dose is 30 mg twice daily, titrated every 2 to 4 weeks to normalize serum calcium levels. 2

From the Research

Treatment Options for Hyperparathyroidism

• Cinacalcet is a commonly used treatment for secondary hyperparathyroidism, particularly in patients with chronic kidney disease (CKD) 3, 4.
• The combination of cinacalcet and vitamin D has been shown to be effective in lowering serum calcium, phosphorus, and calcium-phosphorus product in patients with secondary hyperparathyroidism 5.
• Parathyroidectomy is the only definitive management for primary hyperparathyroidism and is recommended for all symptomatic patients and most asymptomatic patients 6.
• Cinacalcet has also been used to treat secondary hyperparathyroidism in patients with advanced CKD before initiation of regular dialysis, with significant reductions in intact parathyroid hormone (iPTH) levels 7.

Efficacy and Safety of Cinacalcet

• Cinacalcet has been shown to significantly reduce iPTH levels, calcium, phosphorus, and calcium-phosphorus product in patients with secondary hyperparathyroidism 3, 4, 7.
• The most common adverse effects of cinacalcet are nausea and vomiting, with transient episodes of hypocalcemia also reported 3, 4, 5.
• Cinacalcet has been well tolerated in patients with CKD, with no significant increase in adverse events or mortality 5.

Surgical Management of Primary Hyperparathyroidism

• Parathyroidectomy is the only definitive management for primary hyperparathyroidism and is recommended for all symptomatic patients and most asymptomatic patients 6.
• Minimally invasive parathyroidectomy and bilateral exploration are both appropriate operations that achieve high cure rates 6.
• Intraoperative parathyroid hormone monitoring is recommended for minimally invasive parathyroidectomy 6.