From the Guidelines
Elevated PTH levels require a comprehensive approach to determine the underlying cause and appropriate treatment, prioritizing the assessment of serum calcium levels, vitamin D status, and kidney function, as these factors are crucial in guiding treatment decisions and minimizing the risk of morbidity and mortality associated with secondary hyperparathyroidism, as highlighted in the 2018 clinical practice guideline update by the Kidney Disease: Improving Global Outcomes (KDIGO) 1.
When evaluating elevated PTH levels, it is essential to consider the following steps:
- Check serum calcium levels to differentiate between primary and secondary hyperparathyroidism.
- Assess vitamin D levels, as deficiency is a common cause of secondary hyperparathyroidism, and consider supplementation with 50,000 IU of vitamin D2 or D3 weekly for 8 weeks, followed by maintenance doses of 1,000-2,000 IU daily, as recommended by the KDIGO guidelines 1.
- Ensure adequate dietary calcium intake of 1000-1200 mg daily to support bone health.
- Evaluate kidney function using serum creatinine tests, as chronic kidney disease (CKD) is a significant cause of secondary hyperparathyroidism, and consider the use of calcitriol and vitamin D analogues in patients with CKD G4 to G5 and severe, progressive hyperparathyroidism, as suggested by the KDIGO guidelines 1.
- Increase weight-bearing exercise and reduce sodium intake to maintain bone health and minimize the risk of cardiovascular complications associated with CKD.
The management of elevated PTH levels should be guided by the most recent and highest-quality evidence, which emphasizes the importance of individualized treatment approaches, careful monitoring of serum calcium, phosphorus, and PTH levels, and the judicious use of vitamin D sterols and other therapies to minimize the risk of adverse effects and optimize patient outcomes, as highlighted in the studies by 1.
In adult patients with CKD G3a to G5 not on dialysis, calcitriol and vitamin D analogues should not be routinely used, but rather reserved for patients with severe and progressive hyperparathyroidism, as recommended by the KDIGO guidelines 1.
By prioritizing a comprehensive and individualized approach to the management of elevated PTH levels, clinicians can minimize the risk of morbidity and mortality associated with secondary hyperparathyroidism and optimize patient outcomes, as emphasized by the studies by 1.
From the FDA Drug Label
Adynamic Bone Disease: May develop if iPTH levels are suppressed below 100 pg/mL. (5.4)
The implications of elevated Parathyroid Hormone (PTH) levels are not directly stated in the provided drug labels. However, it can be inferred that elevated iPTH levels are associated with Secondary Hyperparathyroidism (HPT), which is an indication for cinacalcet treatment.
- Key points:
- Cinacalcet is used to treat Secondary Hyperparathyroidism (HPT) in adult patients with chronic kidney disease (CKD) on dialysis.
- The goal of cinacalcet treatment is to achieve targeted intact parathyroid hormone (iPTH) levels.
- Suppression of iPTH levels below 100 pg/mL may lead to Adynamic Bone Disease 2 2.
From the Research
Implications of Elevated Parathyroid Hormone (PTH) Levels
- Elevated PTH levels after parathyroidectomy for primary hyperparathyroidism can occur in a significant percentage of patients, with studies reporting a range of 12% to 43% 3, 4, 5.
- The etiology of elevated PTH levels in these patients is likely multifactorial, with possible causes including:
- Elevated PTH levels can also be seen in patients with normocalcemic primary hyperparathyroidism (NPHPT), which is characterized by autonomous parathyroid function 6.
- Differentiation between NPHPT and secondary hyperparathyroidism (SHPT) can be difficult, and careful exclusion of causes of SHPT is necessary to make a diagnosis of NPHPT 6.
- The clinical presentation of primary hyperparathyroidism can vary, with three phenotypes: target organ involvement of the renal and skeletal systems, mild asymptomatic hypercalcemia, and high PTH levels in the context of persistently normal albumin-corrected and ionized serum calcium values 7.
- Guidelines for surgical removal of hyperfunctioning parathyroid tissue apply to all three clinical forms of the disease, and pharmacological approaches are available for patients who do not meet surgical guidelines or have medical contraindications to surgery 7.
- Patients with persistent PTH elevation after parathyroidectomy should be monitored over time for recurrence of primary hyperparathyroidism and other possible complications 5.