From the Guidelines
The recommended management for patients with hyperparathyroidism is surgical removal of the affected parathyroid gland, specifically parathyroidectomy, for symptomatic primary hyperparathyroidism and for asymptomatic patients who meet certain criteria, such as serum calcium >1 mg/dL above normal range, osteoporosis, reduced kidney function, kidney stones, or age under 50 years. For patients with primary hyperparathyroidism, the most common form of hyperparathyroidism, treatment typically involves surgical excision of the abnormally functioning parathyroid tissue, as stated in the study by 1. There are two accepted curative operative strategies for primary hyperparathyroidism: bilateral neck exploration (BNE) and minimally invasive parathyroidectomy (MIP), with MIP being less invasive and often preferred for patients with a single adenoma, as noted in the study by 1. For patients who cannot undergo surgery or have mild disease, medical management includes maintaining adequate hydration, moderate calcium intake, avoiding vitamin D deficiency, and regular monitoring of serum calcium and renal function, as well as pharmacologic options like cinacalcet and bisphosphonates, as discussed in the study by 1. Regular monitoring of calcium, phosphorus, PTH levels, bone density, and renal function is essential for all patients with hyperparathyroidism to prevent complications, as emphasized in the study by 1. In cases of secondary hyperparathyroidism, often seen in kidney disease, treatment involves addressing the underlying cause, using phosphate binders, vitamin D analogs, and sometimes calcimimetics, as outlined in the study by 1. Key considerations in the management of hyperparathyroidism include:
- Surgical removal of the affected parathyroid gland for symptomatic primary hyperparathyroidism and for asymptomatic patients who meet certain criteria
- Medical management for patients who cannot undergo surgery or have mild disease
- Regular monitoring of serum calcium, phosphorus, PTH levels, bone density, and renal function to prevent complications
- Addressing the underlying cause in cases of secondary hyperparathyroidism. Overall, the management of hyperparathyroidism should prioritize reducing morbidity, mortality, and improving quality of life, as supported by the studies by 1.
From the FDA Drug Label
1 INDICATIONS AND USAGE
Cinacalcet tablets are indicated for the treatment of secondary hyperparathyroidism (HPT) in adult patients with chronic kidney disease (CKD) on dialysis
2 DOSAGE AND ADMINISTRATION
The recommended starting oral dose of cinacalcet tablets is 30 mg once daily. 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.
2.3 Patients with Parathyroid Carcinoma and Primary Hyperparathyroidism
The recommended starting oral dose of cinacalcet tablets is 30 mg twice daily. The dose of cinacalcet tablets should be titrated every 2 to 4 weeks through sequential doses of 30 mg twice daily, 60 mg twice daily, and 90 mg twice daily, and 90 mg 3 or 4 times daily as necessary to normalize serum calcium levels
The recommended management for patients with hyperparathyroidism includes:
- For secondary hyperparathyroidism in patients with chronic kidney disease (CKD) on dialysis:
- Starting dose of cinacalcet is 30 mg once daily
- Titration every 2 to 4 weeks to target iPTH levels of 150 to 300 pg/mL
- For parathyroid carcinoma and primary hyperparathyroidism:
From the Research
Evaluation of Hyperparathyroidism
The evaluation of hyperparathyroidism involves assessing the severity of the disease and determining the appropriate management strategy.
- The majority of individuals with primary hyperparathyroidism (PHPT) present at an asymptomatic stage, without any signs or symptoms of calcium or parathyroid hormone (PTH) excess or target organ damage 3.
- Indications for surgery have recently been revised, and parathyroidectomy is advised in patients younger than 50 years old and in the presence of either significant hypercalcemia, impaired renal function, renal stones, or osteoporosis 3.
Management of Hyperparathyroidism
The management of hyperparathyroidism depends on the severity of the disease and the presence of any complications.
- Medical management may be considered in those with mild asymptomatic disease, contraindications to surgery, or failed previous surgical intervention 3.
- Calcium and vitamin D intake should be optimized, and antiresorptive therapy may be used for skeletal protection in patients with an increased fracture risk 3.
- Cinacalcet, a calcimimetic agent, has been shown to effectively lower serum calcium and PTH levels in patients with PHPT 3, 4, 5, 6, 7.
- The efficacy of cinacalcet has been demonstrated in patients with PHPT across a wide spectrum of disease severity, and it is well tolerated 4, 6, 7.
Medical Interventions
Medical interventions play a crucial role in the management of hyperparathyroidism.
- Cinacalcet has been shown to reduce serum calcium concentrations in patients with intractable PHPT 7.
- The long-term tolerability, safety, and efficacy of cinacalcet in PHPT patients have been evaluated, and it has been found to improve biochemical measures of PHPT, including reducing serum calcium and PTH, and increasing serum phosphate 6.
- Cinacalcet may be considered to reduce serum calcium and PTH levels in patients with PHPT who cannot or will not undergo surgery and those with refractory PHPT after parathyroidectomy 5.