From the Guidelines
If your parathyroid hormone (PTH) is high, the most effective treatment approach is to first determine the underlying cause through additional blood tests to check calcium, vitamin D, and kidney function levels, and then consider surgical removal of the affected parathyroid gland(s) or medical management with medications like cinacalcet or vitamin D analogs, depending on the specific diagnosis and clinical context, as supported by recent studies 1.
Determining the Underlying Cause
To address high PTH levels, it is crucial to identify the underlying cause, which could be primary hyperparathyroidism, secondary hyperparathyroidism due to vitamin D deficiency, or kidney disease. Additional blood tests are necessary to check calcium, vitamin D, and kidney function levels.
Treatment Approaches
- For primary hyperparathyroidism with elevated calcium, surgical removal of the affected parathyroid gland(s) is the definitive treatment, as it directly addresses the source of the elevated PTH levels 1.
- If surgery isn't an option, medications like cinacalcet (30-90 mg twice daily) can help lower PTH levels by mimicking calcium's action on the parathyroid gland, thereby reducing PTH secretion.
- For secondary hyperparathyroidism due to vitamin D deficiency, supplementation with vitamin D3 (typically 1,000-2,000 IU daily) is recommended, as vitamin D plays a critical role in regulating PTH levels and bone health.
- If kidney disease is causing the elevated PTH, treatments may include vitamin D analogs like calcitriol (0.25-1 mcg daily), phosphate binders such as sevelamer (800-1600 mg with meals), and dietary phosphorus restriction to manage the metabolic disturbances associated with chronic kidney disease.
Lifestyle Modifications
Lifestyle modifications for all patients with high PTH levels include:
- Adequate hydration to help maintain calcium balance and overall health.
- Moderate calcium intake (1,000-1,200 mg daily) to support bone health without exacerbating hypercalcemia.
- Regular exercise to improve bone density and overall cardiovascular health.
Monitoring and Follow-Up
High PTH levels require regular monitoring because chronic elevation can lead to bone loss, kidney stones, and cardiovascular complications. Regular assessment of PTH, calcium, and related parameters is essential to evaluate the effectiveness of the treatment plan and make necessary adjustments.
Given the complexity of PTH measurement and the differences between assay generations, as highlighted in 1, it is important for clinicians to be aware of these nuances when interpreting PTH levels and making clinical decisions. However, the primary focus should remain on addressing the underlying cause of the elevated PTH and implementing evidence-based treatments to improve patient outcomes in terms of morbidity, mortality, and quality of life.
From the FDA Drug Label
Cinacalcet tablets should be titrated no more frequently than every 2 to 4 weeks through sequential doses of 30,60,90,120, and 180 mg once daily to target iPTH levels of 150 to 300 pg/mL. If high PTH levels are present, the dose of cinacalcet should be titrated every 2 to 4 weeks to target iPTH levels of 150 to 300 pg/mL 2.
- The dose can be increased sequentially to 30,60,90,120, and 180 mg once daily.
- Serum calcium and serum phosphorus should be measured within 1 week and intact parathyroid hormone (iPTH) should be measured 1 to 4 weeks after initiation or dose adjustment of cinacalcet.
- Cinacalcet can be used alone or in combination with vitamin D sterols and/or phosphate binders.
- During dose titration, serum calcium levels should be monitored frequently and if levels decrease below the normal range, appropriate steps should be taken to increase serum calcium levels 2.
From the Research
High PTH Levels: Diagnosis and Management
- High levels of parathyroid hormone (PTH) can be caused by primary hyperparathyroidism (PHPT) or secondary hyperparathyroidism, often associated with chronic kidney disease (CKD) 3, 4, 5.
- Diagnosis of PHPT is based on biological tests, including hypercalcemia, inappropriate PTH levels, and hypercalciuria, while secondary hyperparathyroidism requires elimination of other causes and confirmation of elevated PTH levels over time 3, 4.
Treatment Options
- Surgical management of the hyperfunctioning parathyroid gland(s) is the only curative treatment for PHPT, while medical management is reserved for patients who are not candidates for surgery or refuse it 3.
- For secondary hyperparathyroidism, therapeutic intervention aims to enhance serum 25(OH)D levels and reduce PTH levels, employing strategies such as vitamin D supplementation and phosphate binders 4, 5.
- Recent studies have also explored the role of microRNAs (miRNAs) in the pathogenesis of secondary hyperparathyroidism, providing new research directions for diagnosis and treatment 6, 7.
Clinical Considerations
- Patients with high PTH levels should be evaluated for renal and skeletal complications, such as nephrolithiasis, osteoporosis, and fractures 3.
- The management of secondary hyperparathyroidism is crucial in preventing the development of bone disease and vascular calcification in patients with CKD 5.
- A multidisciplinary approach, including endocrinologists and nephrologists, is essential for the diagnosis and management of high PTH levels 3, 4, 5.