What is the next step for an 88-year-old female with hypercalcemia, a benign right parathyroid mass, and impaired renal function, with a history of hypothyroidism status post Radioactive Iodine (RAI) ablation?

From the Guidelines

The next recommended step for this 88-year-old female with hypercalcemia, a benign parathyroid mass, and moderate renal impairment is parathyroidectomy. Surgical removal of the abnormal parathyroid gland is indicated because she has primary hyperparathyroidism with symptomatic hypercalcemia (calcium level of 2.89 mmol/L) and evidence of end-organ damage (reduced kidney function with eGFR of 49) 1. Prior to surgery, she should undergo localization studies such as sestamibi scan and/or ultrasound to confirm the location of the abnormal gland, though the biopsy has already identified the right parathyroid mass. Preoperative optimization should include adequate hydration and possibly cinacalcet (30mg daily, titrated as needed) to temporarily control calcium levels if surgery must be delayed 1. The patient's hypothyroidism should be well-controlled before surgery, and her renal function should be closely monitored. Parathyroidectomy is curative in about 95% of cases and would address the underlying cause of hypercalcemia, preventing further deterioration of kidney function and other complications of chronic hypercalcemia such as osteoporosis and nephrolithiasis. Some key points to consider in the management of this patient include:

• The importance of controlling hypercalcemia to prevent further kidney damage and other complications 1
• The need for careful preoperative evaluation and optimization to minimize the risk of surgery 1
• The potential benefits of parathyroidectomy in improving kidney function and reducing the risk of long-term complications 1
• The importance of monitoring renal function and adjusting treatment as needed to prevent hypercalcemia and other complications 1

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Cinacalcet tablets should be taken with food or shortly after a meal (2.1) Secondary HPT in patients with CKD on dialysis (2. 2): Starting dose is 30 mg once daily. Hypercalcemia in patients with PC or hypercalcemia in patients with primary HPT (2. 3): Starting dose is 30 mg twice daily.

The patient has a benign parathyroid mass and elevated calcium levels, which suggests primary hyperparathyroidism (HPT). Given the patient's eGFR/creatine of 49/91, indicating chronic kidney disease (CKD), but not explicitly on dialysis, the most relevant dosing information is for hypercalcemia in patients with primary HPT.

• The recommended starting dose for hypercalcemia in patients with primary HPT is 30 mg twice daily.
• The patient's renal function should be considered when initiating cinacalcet, but the label does not provide specific guidance for patients with CKD not on dialysis. The next recommended step would be to consider starting the patient on cinacalcet 30 mg twice daily and monitor serum calcium levels every 2 months, while also considering the patient's renal function and overall clinical status 2.

From the Research

Patient Presentation

The patient is an 88-year-old female with a history of hypothyroidism, status post radioactive iodine (RAI) treatment, presenting with elevated calcium levels (2.89 mmol/L) and a benign right parathyroid mass. She also has impaired renal function, as indicated by an eGFR of 49 and a creatinine level of 91.

Diagnosis and Management

• The patient's hypercalcemia is likely due to primary hyperparathyroidism (PHPT), given the presence of a parathyroid mass and elevated calcium levels 3, 4, 5.
• The management of PHPT depends on the severity of hypercalcemia, age, and presence of target organ damage 6.
• In patients older than 50 years with mild hypercalcemia and no evidence of skeletal or kidney disease, observation may be appropriate 3.
• However, given the patient's impaired renal function, parathyroidectomy may be considered to prevent further renal deterioration 6.
• Medical management, including optimization of calcium and vitamin D intake, antiresorptive therapy, and cinacalcet, may also be considered in patients who are not suitable candidates for surgery or have mild asymptomatic disease 6.

Treatment Options

• Parathyroidectomy is the only curative treatment for PHPT, but it may not be suitable for all patients, especially those with significant comorbidities 4, 5.
• Medical management, including bisphosphonates, calcimimetics, and denosumab, may be used to control hypercalcemia and prevent target organ damage 4, 5, 6.
• The choice of treatment should be individualized based on the patient's age, comorbidities, and severity of hypercalcemia 3, 4, 5, 6, 7.

Next Steps

• Further evaluation of the patient's renal function and assessment of her overall health status are necessary to determine the best course of treatment 3, 4, 5, 6, 7.
• Consultation with an endocrinologist or a surgeon may be necessary to discuss the risks and benefits of parathyroidectomy versus medical management 6.