What is the treatment for hyperparathyroidism (Primary Hyperparathyroidism)?

From the Guidelines

Hyperparathyroidism is primarily treated through surgical excision of the abnormally functioning parathyroid tissue, which is typically indicated even in asymptomatic patients due to the potential negative effects of long-term hypercalcemia. The treatment approach for primary hyperparathyroidism (PHPT) involves two accepted curative operative strategies: bilateral neck exploration (BNE) and minimally invasive parathyroidectomy (MIP) 1. BNE is a bilateral operation where all parathyroid glands are identified and examined, and the diseased glands are resected. MIP, on the other hand, is a unilateral operation that utilizes limited dissection for targeted removal of only the affected gland, which is less invasive than BNE.

Key considerations for the treatment of PHPT include:

• The role of imaging in PHPT is to localize the abnormally functioning gland or glands with high accuracy and high confidence to facilitate targeted curative surgery 1.
• Intraoperative PTH monitoring is used to confirm removal of the hyperfunctioning gland 1.
• Parathyroid reoperations are surgically challenging, with lower cure rates than first-time surgery and higher complication rates, making preoperative imaging essential in the reoperative setting 1.
• Treatment goals include normalizing calcium levels and preventing complications like osteoporosis, kidney stones, and cardiovascular calcifications.

In terms of specific treatment approaches, MIP is often preferred for patients with a single adenoma, as it conveys the benefits of shorter operating times, faster recovery, and decreased perioperative costs 1. However, BNE remains the necessary method in cases of discordant or nonlocalizing preoperative imaging or when there is high suspicion for multigland disease. Regular monitoring of calcium, phosphorus, and PTH levels is essential for all patients, with treatment adjustments based on these values 1.

From the FDA Drug Label

1 INDICATIONS AND USAGE

1.1 Secondary Hyperparathyroidism 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)]. 1.2 Parathyroid Carcinoma Cinacalcet tablets are indicated for the treatment of hypercalcemia in adult patients with Parathyroid Carcinoma [see Clinical Studies(14.2)].

1. 3 Primary Hyperparathyroidism 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)].

Treatment of Hyperparathyroidism includes:

• Cinacalcet tablets for the treatment of secondary hyperparathyroidism in adult patients with chronic kidney disease (CKD) on dialysis.
• Cinacalcet tablets for the treatment of hypercalcemia in adult patients with Parathyroid Carcinoma.
• Cinacalcet tablets for the treatment of hypercalcemia in adult patients with primary hyperparathyroidism who are unable to undergo parathyroidectomy 2.

From the Research

Treatment Options for Hyperparathyroidism

• The treatment of hyperparathyroidism depends on the underlying cause and severity of the condition 3, 4.
• For primary hyperparathyroidism, surgery is often the recommended treatment, with partial or full parathyroidectomy being performed to correct the underlying condition 3.
• In cases of secondary hyperparathyroidism, treatment typically involves medical management with phosphate binders, vitamin D analogs, and calcimimetics 3, 5.
• For tertiary hyperparathyroidism, treatment may involve a combination of medical and surgical approaches, with the goal of reducing parathyroid hormone levels and preventing complications 4.
• In some cases, native vitamin D supplementation may be used to prevent secondary hyperparathyroidism in patients with chronic kidney disease 6.

Medical Management

• Calcimimetics, such as cinacalcet, may be used to manage secondary hyperparathyroidism by reducing parathyroid hormone levels and slowing the progression of parathyroid gland hyperplasia 5.
• Vitamin D analogs and phosphate binders may also be used to manage secondary hyperparathyroidism 3, 6.
• In cases of severe hypercalcemia, emergency treatment may be required, with hydration, calciuresis, and inhibition of bone calcium resorption being key components of treatment 7.

Surgical Treatment

• Parathyroidectomy may be performed in cases of primary, secondary, or tertiary hyperparathyroidism that are unresponsive to medical treatment 3, 4.
• The decision to perform surgery should be made on a case-by-case basis, taking into account the individual patient's clinical condition and medical history 4.