When should I initiate treatment for hyperparathyroidism?

From the Guidelines

Treatment for hyperparathyroidism should be initiated in patients with severe hyperparathyroidism, characterized by persistent serum levels of intact PTH >800 pg/mL, associated with hypercalcemia and/or hyperphosphatemia that are refractory to medical therapy. This recommendation is based on the guidelines outlined in the K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease 1. The primary treatment for severe hyperparathyroidism is surgical removal of the abnormal parathyroid gland(s), called parathyroidectomy, which can be accomplished by subtotal parathyroidectomy or total parathyroidectomy with parathyroid tissue autotransplantation 1.

Key Considerations for Treatment

• Severe hyperparathyroidism is defined by persistent serum levels of intact PTH >800 pg/mL, associated with hypercalcemia and/or hyperphosphatemia that are refractory to medical therapy 1
• Parathyroidectomy is the primary treatment for severe hyperparathyroidism, with options including subtotal parathyroidectomy or total parathyroidectomy with parathyroid tissue autotransplantation 1
• Post-operative care includes monitoring of ionized calcium levels and initiation of calcium gluconate infusion if levels fall below normal, with adjustments to maintain normal ionized calcium levels 1

Post-Operative Management

• Monitoring of ionized calcium levels every 4 to 6 hours for the first 48 to 72 hours after surgery, and then twice daily until stable 1
• Initiation of calcium gluconate infusion at a rate of 1 to 2 mg elemental calcium per kilogram body weight per hour if ionized calcium levels fall below normal, with adjustments to maintain normal ionized calcium levels 1

From the FDA Drug Label

Cinacalcet tablet is a positive modulator of the calcium sensing receptor indicated for: • Secondary Hyperparathyroidism (HPT) in adult patients with chronic kidney disease (CKD) on dialysis. • Hypercalcemia in adult patients with Parathyroid Carcinoma (PC). • 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.

The decision to initiate treatment for hyperparathyroidism should be based on the presence of one of the indicated conditions, such as Secondary Hyperparathyroidism (HPT) in adult patients with chronic kidney disease (CKD) on dialysis, Hypercalcemia in adult patients with Parathyroid Carcinoma (PC), or Hypercalcemia in adult patients with primary HPT for whom parathyroidectomy would be indicated. Key considerations for treatment initiation include:

• The patient's serum calcium levels
• The presence of chronic kidney disease (CKD) on dialysis
• The presence of Parathyroid Carcinoma (PC) or primary HPT
• The inability to undergo parathyroidectomy due to serum calcium levels or other factors 2

From the Research

Initiation of Treatment for Hyperparathyroidism

The decision to initiate treatment for hyperparathyroidism depends on various factors, including the patient's age, serum calcium level, and presence of symptoms or target organ damage.

• Patients younger than 50 years old with significant hypercalcemia, impaired renal function, renal stones, or osteoporosis are advised to undergo parathyroidectomy 3.
• Surgery is also recommended for patients with symptomatic hyperparathyroidism, such as those with nausea, vomiting, dehydration, confusion, somnolence, or coma 4.
• For patients with mild asymptomatic disease, medical management may be considered, including optimization of calcium and vitamin D intake, antiresorptive therapy for skeletal protection, and cinacalcet to lower serum calcium and parathyroid hormone levels 3, 5, 6, 7.
• In patients older than 50 years with serum calcium levels less than 1 mg above the upper normal limit and no evidence of skeletal or kidney disease, observation may be appropriate 4.

Medical Management

Medical management of hyperparathyroidism includes:

• Optimization of calcium and vitamin D intake 3
• Antiresorptive therapy, such as bisphosphonates, to reduce the risk of fractures 3, 4
• Cinacalcet, a calcimimetic agent, to lower serum calcium and parathyroid hormone levels 5, 6, 7
• Glucocorticoids may be used as primary treatment when hypercalcemia is due to excessive intestinal calcium absorption 4

Surgical Intervention

Surgical intervention, such as parathyroidectomy, is recommended for:

• Patients with symptomatic hyperparathyroidism 4
• Patients with significant hypercalcemia, impaired renal function, renal stones, or osteoporosis 3
• Patients younger than 50 years old 3
• Patients who have failed medical management or have contraindications to medical therapy 3, 7