From the Guidelines
Elevation in parathyroid hormone (PTH) should be managed based on the underlying cause, with a focus on treating secondary hyperparathyroidism in patients with chronic kidney disease (CKD) using a combination of vitamin D supplementation, calcium supplements, phosphate binders, and calcimimetics, as well as considering surgical parathyroidectomy in severe cases, as recommended by the most recent guidelines 1.
Causes and Management of Hyperparathyroidism
Elevation in parathyroid hormone (PTH) occurs when the body detects low calcium levels in the blood, triggering the parathyroid glands to release more PTH to restore calcium balance. This condition, known as hyperparathyroidism, can be primary (due to overactive parathyroid glands), secondary (resulting from chronic kidney disease or vitamin D deficiency), or tertiary (persistent hyperparathyroidism after long-standing secondary hyperparathyroidism). Management depends on the underlying cause.
- For primary hyperparathyroidism, surgical removal of the affected gland(s) is often recommended, especially in symptomatic patients or those with significant bone loss or kidney stones.
- For secondary hyperparathyroidism, treating the underlying condition is essential, which may include:
- Vitamin D supplementation (typically 1,000-2,000 IU daily) 1
- Calcium supplements (500-1,000 mg daily)
- Phosphate binders like sevelamer for patients with kidney disease
- Calcimimetics such as cinacalcet (starting at 30 mg daily) to reduce PTH secretion
Surgical Parathyroidectomy
Surgical parathyroidectomy is indicated in severe cases of hyperparathyroidism, particularly in patients with CKD who have failed medical therapy or have significant hypercalcemia or hyperphosphatemia 1. The choice of surgical procedure, including subtotal or total parathyroidectomy with or without autotransplantation, depends on the surgeon's preference and the patient's individual needs. Recent studies suggest that total parathyroidectomy with autotransplantation (TPTX + AT) may be an effective option for patients with secondary hyperparathyroidism, as it can reduce the risk of recurrence and improve long-term outcomes 1.
Monitoring and Prevention
Regular monitoring of calcium, phosphorus, and PTH levels is crucial for all patients with elevated PTH. Untreated hyperparathyroidism can lead to bone disease, kidney stones, cardiovascular complications, and neuropsychiatric symptoms, making prompt diagnosis and appropriate management essential for preventing long-term complications. Prevention of secondary hyperparathyroidism in patients with CKD involves managing modifiable risk factors, such as high phosphate intake, vitamin D deficiency, and hypocalcemia, as well as using calcitriol and vitamin D analogues judiciously 1.
From the FDA Drug Label
Cinacalcet tablet is a positive modulator of the calcium sensing receptor indicated for: • Secondary Hyperparathyroidism (HPT) in adult patients with chronic kidney disease (CKD) on dialysis. Secondary HPT in patients with CKD on dialysis (2. 2): Starting dose is 30 mg once daily. Titrate dose no more frequently than every 2 to 4 weeks through sequential doses of 30,60,90,120, and 180 mg once daily as necessary to achieve targeted intact parathyroid hormone (iPTH) levels.
The medication cinacalcet is used to treat elevation in parathyroid hormone levels, specifically in patients with secondary hyperparathyroidism due to chronic kidney disease on dialysis. The goal of treatment is to achieve targeted intact parathyroid hormone (iPTH) levels by titrating the dose of cinacalcet. 2
From the Research
Elevation in Parathyroid Hormone
Elevation in parathyroid hormone (PTH) can be caused by various factors, including:
- Primary hyperparathyroidism (PHPT), which is the most common cause of hypercalcemia 3
- Vitamin D deficiency, which can stimulate parathyroid secretion 4, 5, 6, 7
- Secondary hyperparathyroidism, which can arise as a result of reduced vitamin D levels 4
Relationship between Vitamin D and Parathyroid Hormone
The interplay between vitamin D and PTH represents one of the most important metabolic mechanisms of regulation of the calcium/phosphorus homeostasis 4. Vitamin D deficiency can lead to an increase in PTH levels, which can cause hypercalcemia and other clinical complications 4, 5, 6, 7.
Clinical Presentations of Primary Hyperparathyroidism
The clinical presentation of PHPT can vary and includes three phenotypes:
- Target organ involvement of the renal and skeletal systems
- Mild asymptomatic hypercalcemia
- High PTH levels in the context of persistently normal albumin-corrected and ionized serum calcium values 3
Treatment of Primary Hyperparathyroidism
Guidelines for surgical removal of hyperfunctioning parathyroid tissue apply to all three clinical forms of the disease 3. Vitamin D supplementation can also be an effective treatment option for patients with PHPT and vitamin D deficiency, as it can reduce PTH and alkaline phosphatase (ALP) levels without causing hypercalcemia and hypercalciuria 5.