From the Guidelines
Management of secondary hyperparathyroidism typically involves a multi-faceted approach aimed at normalizing calcium, phosphate, and parathyroid hormone (PTH) levels, with the primary treatment strategy including dietary phosphate restriction, phosphate binders, vitamin D analogs, and calcimimetics, as recommended by the most recent guidelines 1. The treatment approach should be individualized based on the severity of secondary hyperparathyroidism and the patient's response to therapy.
- Start by limiting dietary phosphate intake to 800-1000 mg/day.
- Prescribe phosphate binders such as calcium acetate (667 mg with meals) or sevelamer (800-1600 mg with meals) to further reduce phosphate absorption.
- Administer active vitamin D analogs like calcitriol (0.25-1 μg/day) or paricalcitol (1-2 μg daily to thrice weekly) to suppress PTH production and improve calcium absorption, with the dosage adjusted according to the severity of secondary hyperparathyroidism 1.
- For patients with persistently elevated PTH levels, add a calcimimetic like cinacalcet, starting at 30 mg daily and titrating up to a maximum of 180 mg daily as needed.
- In severe cases unresponsive to medical management, consider referral for parathyroidectomy, with the choice of surgical procedure, such as subtotal or total parathyroidectomy, with or without implantation of parathyroid tissue, depending on the surgeon's discretion and the patient's individual needs 1. Regular monitoring of serum calcium, phosphate, and PTH levels is crucial to guide treatment adjustments, with the goal of achieving PTH levels between 150-300 pg/mL in patients with chronic kidney disease, as this comprehensive approach addresses the underlying mechanisms of secondary hyperparathyroidism and prevents complications such as bone disease and vascular calcification 1.
From the FDA Drug Label
The recommended starting oral dose of cinacalcet tablets is 30 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 tablets. 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. Cinacalcet tablets 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, such as by providing supplemental calcium, initiating or increasing the dose of calcium-based phosphate binder, initiating or increasing the dose of vitamin D sterols, or temporarily withholding treatment with cinacalcet tablets.
The management of secondary hyperparathyroidism in patients with chronic kidney disease on dialysis involves the use of cinacalcet tablets, which should be initiated at a dose of 30 mg once daily and titrated every 2 to 4 weeks to target iPTH levels of 150 to 300 pg/mL.
- Key steps in management include:
- Monitoring serum calcium and serum phosphorus within 1 week of initiation or dose adjustment
- Monitoring intact parathyroid hormone (iPTH) 1 to 4 weeks after initiation or dose adjustment
- Adjusting the dose of cinacalcet tablets as needed to maintain target iPTH levels
- Using cinacalcet tablets alone or in combination with vitamin D sterols and/or phosphate binders
- Monitoring serum calcium levels frequently during dose titration and taking steps to increase serum calcium levels if they decrease below the normal range 2 2
From the Research
Management of Secondary Hyperparathyroidism
The management of secondary hyperparathyroidism involves several strategies, including:
- Dietary phosphate restriction and phosphate binders to control serum phosphate levels 3
- Administration of vitamin D or vitamin D analogs, such as calcitriol or paricalcitol, to suppress parathyroid hormone (PTH) secretion 4, 5, 3, 6
- Use of calcimimetics, which stimulate the calcium-sensing receptor of parathyroid cells and suppress PTH secretion 5, 3
- Percutaneous direct injection therapy of vitamin D, vitamin D analogs, or calcimimetics into the parathyroid gland 5
- Parathyroidectomy in cases where pharmacological treatment fails 3
Treatment Options
The choice of treatment depends on the stage of chronic kidney disease (CKD) and the type of biochemical abnormalities present. Treatment options include:
- Calcitriol or its analogs, such as alfacalcidol or paricalcitol, to manage deficiency of 1,25(OH)2D 3
- Calcimimetics, which can be used alone or in combination with vitamin D compounds 3
- Phosphate binders, such as sevelamer hydrochloride, to control serum phosphate levels 5
Comparison of Treatment Options
Studies have compared the effectiveness of different treatment options, including:
- Paricalcitol versus calcitriol in the treatment of secondary hyperparathyroidism, with paricalcitol showing a faster reduction in PTH levels and fewer episodes of hypercalcemia and elevated Ca x P product 4, 7
- Conversion from calcitriol to paricalcitol resulting in lower serum calcium, phosphorus, and Ca x P product, as well as reduced PTH and alkaline phosphatase levels 7