What are the treatment options for hyperparathyroidism (Primary Hyperparathyroidism)?

From the Guidelines

The most effective treatment for hyperparathyroidism is 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 depends on the severity, cause, and symptoms of hyperparathyroidism. For primary hyperparathyroidism (PHPT), there are 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, while MIP is a unilateral operation that utilizes limited dissection for targeted removal of the affected gland. Some key points to consider in the treatment of hyperparathyroidism include:

• MIP is often preferred for patients with a single adenoma, as it conveys benefits such as shorter operating times, faster recovery, and decreased perioperative costs 1.
• Preoperative localization of the parathyroid adenoma is crucial for MIP, and intraoperative PTH monitoring is used to confirm removal of the hyperfunctioning gland 1.
• Imaging has no utility in confirming or excluding the diagnosis of PHPT, but it plays a critical role in localizing the abnormally functioning gland or glands to facilitate targeted curative surgery 1.
• Parathyroid reoperations are surgically challenging, with lower cure rates and higher complication rates, emphasizing the importance of accurate preoperative imaging in the reoperative setting 1.
• Medical management options, such as cinacalcet and bisphosphonates, may be considered for patients who are not suitable for surgery or have mild disease, but these should be used under the guidance of a healthcare professional and with regular monitoring of calcium, phosphorus, and PTH levels. The goal of treatment is to achieve normocalcemia, prevent long-term complications, and improve quality of life, and the choice of treatment should be individualized based on the patient's specific needs and circumstances.

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)].

Treatment of Hyperparathyroidism:

• Secondary Hyperparathyroidism: Cinacalcet is indicated for the treatment of secondary hyperparathyroidism in adult patients with chronic kidney disease (CKD) on dialysis.
• Parathyroid Carcinoma: Cinacalcet is indicated for the treatment of hypercalcemia in adult patients with parathyroid carcinoma.
• Primary Hyperparathyroidism: Cinacalcet is indicated for the treatment of hypercalcemia in adult patients with primary hyperparathyroidism who are unable to undergo parathyroidectomy. The recommended starting dose is 30 mg once daily for secondary hyperparathyroidism and 30 mg twice daily for parathyroid carcinoma and primary hyperparathyroidism 2.

From the Research

Treatment Options for Hyperparathyroidism

• Surgical treatment is considered the only curative treatment for primary hyperparathyroidism (pHPT) 3
• Bilateral neck exploration (BNE) and minimally invasive parathyroidectomy (MIP) are two main surgical options used to treat HPT 3
• BNE remains the gold standard procedure in parathyroid surgery, while MIP is the standard treatment option in selected patients with positive imaging 3

Medical Management of Hyperparathyroidism

• Calcimimetics, such as cinacalcet, are used to manage secondary hyperparathyroidism among patients undergoing dialysis regularly 4
• Cinacalcet acts as an allosteric activator of the calcium-sensing receptor, which controls parathyroid hormone secretion 4
• Calcimimetics have diverse effects on parathyroid gland function and may enhance the overall medical management of secondary hyperparathyroidism 4
• Other therapeutic options, such as bisphosphonates and denosumab, are being evaluated for the medical management of primary hyperparathyroidism 5

Surgical Treatment for High-Risk Patients

• Patients with a high risk of hypercalcaemic crisis due to primary hyperparathyroidism (PHPT) require urgent surgical intervention and removal of diseased parathyroid glands 6
• Bilateral neck exploration was performed in all patients with the removal of the affected parathyroid gland and biopsies of other parts, resulting in a statistically significant decrease in PTH and iCa levels 6
• Surgery should be performed as soon as possible, even if there are no imaging tests, only based on an assessment of the general condition of the patient and their serum calcium levels 6