From the Guidelines
The management of hyperparathyroidism depends on its cause, severity, and associated symptoms, with parathyroidectomy being the definitive treatment for primary hyperparathyroidism, especially for symptomatic patients, those under 50 years old, with significantly elevated calcium levels, reduced bone density, or kidney complications. For patients who cannot undergo surgery, medical management includes cinacalcet (starting at 30 mg daily, titrated up to 90 mg 2-4 times daily as needed) to lower PTH and calcium levels, as supported by studies such as 1. Bisphosphonates like alendronate (70 mg weekly) may be used to improve bone density. Adequate hydration and avoiding thiazide diuretics are important supportive measures.
For secondary hyperparathyroidism due to kidney disease, treatment focuses on addressing the underlying cause with vitamin D supplements (calcitriol 0.25-1 mcg daily), phosphate binders (calcium acetate, sevelamer, or lanthanum), and calcimimetics like cinacalcet, as discussed in 1 and 1. Regular monitoring of calcium, phosphorus, and PTH levels is essential for all patients, with adjustments to therapy based on these values. The goal of treatment is to normalize calcium levels, reduce PTH, prevent complications like bone disease and kidney stones, and improve quality of life by addressing symptoms such as fatigue, bone pain, and cognitive changes.
Some key points to consider in the management of hyperparathyroidism include:
- The use of parathyroidectomy as a definitive treatment for primary hyperparathyroidism, with studies such as 1 supporting its effectiveness.
- The importance of medical management for patients who cannot undergo surgery, including the use of cinacalcet and bisphosphonates.
- The need for regular monitoring of calcium, phosphorus, and PTH levels to adjust therapy and prevent complications.
- The use of vitamin D supplements, phosphate binders, and calcimimetics in the treatment of secondary hyperparathyroidism due to kidney disease, as discussed in 1 and 1.
Overall, the management of hyperparathyroidism requires a comprehensive approach that takes into account the underlying cause, severity, and associated symptoms of the disease, with the goal of improving quality of life and preventing complications.
From the FDA Drug Label
1.3 Primary Hyperparathyroidism 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 2.2 Secondary Hyperparathyroidism in Patients with Chronic Kidney Disease on Dialysis The recommended starting oral dose of cinacalcet tablets is 30 mg once daily. 2.3 Patients with Parathyroid Carcinoma and Primary Hyperparathyroidism The recommended starting oral dose of cinacalcet tablets is 30 mg twice daily.
The management approach for patients with hyperparathyroidism (High Parathyroid Hormone (PTH) levels) includes the use of cinacalcet tablets. The dosage and administration of cinacalcet tablets vary depending on the type of hyperparathyroidism.
- For primary hyperparathyroidism, the recommended starting dose is 30 mg twice daily.
- For secondary hyperparathyroidism in patients with chronic kidney disease on dialysis, the recommended starting dose is 30 mg once daily. It is essential to monitor serum calcium and serum phosphorus levels, as well as intact parathyroid hormone (iPTH) levels, during treatment with cinacalcet tablets to adjust the dose as needed and prevent hypocalcemia 2.
From the Research
Management Approach for Hyperparathyroidism
The management approach for patients with hyperparathyroidism (high Parathyroid Hormone (PTH) levels) involves a combination of surgical and medical interventions.
- Surgical intervention, such as parathyroidectomy, is often recommended for patients with significant hypercalcemia, impaired renal function, renal stones, or osteoporosis 3.
- Medical management may be considered for patients with mild asymptomatic disease, contraindications to surgery, or failed previous surgical intervention 3.
- Medical interventions may include:
- Optimizing calcium and vitamin D intake 3
- Antiresorptive therapy for skeletal protection in patients with increased fracture risk 3
- Cinacalcet, a calcimimetic agent, to lower serum calcium and PTH levels 3, 4, 5
- Paricalcitol, a vitamin D analogue, to decrease PTH levels with a lower effect on intestinal calcium and phosphorus absorption 4, 5
Treatment of Secondary Hyperparathyroidism
For patients with secondary hyperparathyroidism, treatment options include:
- Paricalcitol, which has been shown to be effective in reducing PTH levels in hemodialysis patients 4
- Cinacalcet, which can be used in combination with paricalcitol, but may not provide additional benefits 4
- Parathyroidectomy, which may be considered for patients with severe hyperparathyroidism or those who do not respond to medical treatment 6
Factors Predicting Recurrence and Post-Operative Complications
Factors that predict recurrence and post-operative complications in patients with hyperparathyroidism include: