From the Guidelines
The most effective treatment choice for secondary hyperparathyroidism is total parathyroidectomy (TPTX), as it has been shown to reduce the relapse of SHPT and alleviate symptoms, despite potential temporary hypocalcemia, as suggested by recent studies 1.
Treatment Overview
The management of secondary hyperparathyroidism (SHPT) involves a multifaceted approach, including medical therapy and surgical intervention. Initial treatment focuses on controlling phosphate levels through dietary restriction and phosphate binders, as well as vitamin D therapy to suppress PTH secretion.
- Medical therapy includes phosphate binders such as calcium acetate, sevelamer, lanthanum carbonate, or ferric citrate.
- Vitamin D therapy is essential, using calcitriol or vitamin D analogs like paricalcitol to suppress PTH secretion.
- Calcimimetics like cinacalcet or etelcalcetide are effective for patients with persistently elevated PTH despite conventional therapy.
Surgical Intervention
For severe cases unresponsive to medical management, parathyroidectomy may be necessary, particularly when PTH levels exceed 800 pg/mL with associated symptoms or severe bone disease.
- Total parathyroidectomy (TPTX) is recommended as the surgical treatment of choice for SHPT, as it has been shown to reduce the relapse of SHPT and alleviate symptoms, despite potential temporary hypocalcemia, as suggested by recent studies 1.
- TPTX has great advantages over subtotal parathyroidectomy (SPTX) and total parathyroidectomy with autotransplantation (TPTX + AT) in reducing the relapse of SHPT.
- Regular monitoring of calcium, phosphate, and PTH levels is crucial to guide therapy adjustments and prevent complications like calciphylaxis or adynamic bone disease.
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)]. PARSABIV is indicated for the treatment of secondary hyperparathyroidism (HPT) in adult patients with chronic kidney disease (CKD) on hemodialysis.
The treatment choice for secondary hyperparathyroidism includes:
- Cinacalcet (PO): indicated for adult patients with CKD on dialysis 2
- Etelcalcetide (IV): indicated for adult patients with CKD on hemodialysis 3 Key considerations:
- Cinacalcet can be used alone or in combination with vitamin D sterols and/or phosphate binders 2
- Etelcalcetide has not been studied in patients with parathyroid carcinoma, primary hyperparathyroidism, or CKD not on hemodialysis 3
From the Research
Treatment Options for Secondary Hyperparathyroidism
The treatment of secondary hyperparathyroidism (SHPT) typically involves a combination of therapeutic strategies, including:
- Phosphate intake control by diet or phosphate binders
- Vitamin D receptor activators, such as paricalcitol
- Calcimimetics, such as cinacalcet
- Etelcalcetide, a new long-acting peptide that belongs to the calcimimetics class
Comparison of Treatment Strategies
Studies have compared the efficacy of different treatment strategies for SHPT, including:
- Paricalcitol alone versus cinacalcet alone versus combination therapy with paricalcitol and cinacalcet 4, 5
- Cinacalcet plus vitamin D versus vitamin D alone 6
- Etelcalcetide versus placebo or cinacalcet 7
Key Findings
The studies found that:
- Paricalcitol alone was more effective than cinacalcet alone in reducing iPTH levels 4, 5
- Combination therapy with paricalcitol and cinacalcet did not improve treatment outcomes compared to paricalcitol alone 4, 5
- Cinacalcet plus vitamin D significantly lowered serum calcium, phosphorus, and calcium × phosphorus product, but had no effect on serum PTH 6
- Etelcalcetide was more effective than placebo and cinacalcet in reducing PTH levels 7
Safety and Efficacy
The studies also found that:
- The safety profile of paricalcitol alone was comparable to combination therapy with paricalcitol and cinacalcet 4, 5
- Cinacalcet plus vitamin D had a higher risk of hypocalcemia and nausea or vomiting compared to vitamin D alone 6
- Etelcalcetide had a good safety profile, with the most common adverse event being asymptomatic blood calcium reduction 7