What is the treatment for hyperparathyroidism with elevated calcium scores?

From the Guidelines

The treatment for hyperparathyroidism with elevated calcium scores primarily involves surgical removal of the abnormal parathyroid gland(s), known as parathyroidectomy, with total parathyroidectomy (TPTX) being a recommended approach for secondary hyperparathyroidism in patients with chronic kidney disease, as it has been shown to reduce the relapse of SHPT and improve outcomes 1.

Key Considerations

• Before surgery, localization studies like sestamibi scans or ultrasound help identify the affected gland(s) to guide the surgical approach.
• For patients who cannot undergo surgery, medical management options include cinacalcet, which reduces parathyroid hormone (PTH) secretion, and bisphosphonates like alendronate or zoledronic acid to prevent bone loss.
• Adequate hydration and avoiding thiazide diuretics are important supportive measures to manage hypercalcemia.
• For secondary hyperparathyroidism, treatment focuses on addressing the underlying cause with vitamin D supplements, phosphate binders, and dietary phosphorus restriction.
• Regular monitoring of calcium, PTH, and kidney function is essential during treatment to adjust the management plan as needed.

Surgical Approach

• Total parathyroidectomy (TPTX) has been shown to be effective in reducing the relapse of SHPT and improving outcomes in patients with chronic kidney disease 1.
• Subtotal parathyroidectomy (SPTX) and total parathyroidectomy with autotransplantation (TPTX + AT) are also options, but TPTX is recommended due to its advantages in reducing SHPT relapse.
• The choice of surgical approach should be individualized based on the patient's specific condition and the surgeon's experience.

Post-Surgical Management

• After parathyroidectomy, close monitoring of ionized calcium levels is crucial to prevent hypocalcemia, with measurements every 4 to 6 hours for the first 48 to 72 hours, and then twice daily until stable 1.
• If hypocalcemia occurs, calcium gluconate infusion should be initiated at a rate of 1 to 2 mg elemental calcium per kilogram body weight per hour and adjusted to maintain normal ionized calcium levels 1.

From the FDA Drug Label

Cinacalcet tablets are indicated for the treatment of secondary hyperparathyroidism (HPT) in adult patients with chronic kidney disease (CKD) on dialysis [see Clinical Studies (14. 1)]. Cinacalcet tablets are indicated for the treatment of hypercalcemia in adult patients with Parathyroid Carcinoma [see Clinical Studies(14.2)]. 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 [see Clinical Studies (14.3)].

The treatment for hyperparathyroidism with elevated calcium scores is cinacalcet tablets, which can be used to treat:

• Secondary hyperparathyroidism in patients with chronic kidney disease (CKD) on dialysis
• Hypercalcemia in patients with parathyroid carcinoma
• Hypercalcemia in patients with primary hyperparathyroidism who are unable to undergo parathyroidectomy 2

From the Research

Treatment for Hyperparathyroidism with Elevated Calcium Scores

The treatment for hyperparathyroidism with elevated calcium scores can be managed through various methods, including:

• Parathyroidectomy, which 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
• Medical management, which may be considered in those with mild asymptomatic disease, contraindications to surgery, or failed previous surgical intervention 3
• Optimization of calcium and vitamin D intake 3
• Antiresorptive therapy for skeletal protection in patients with an increased fracture risk 3
• Cinacalcet, a calcimimetic agent, which has been shown to effectively lower serum calcium and PTH levels 3, 4, 5, 6, 7

Cinacalcet Treatment

Cinacalcet has been proven to be a reasonable alternative for several patient subgroups, including:

• Patients with hyperplasia in all glands rather than an isolated adenoma 4
• Patients with persisting HPT following unsuccessful surgery or inoperable cases due to comorbidities 4
• Patients detected in lab screens for hypercalcemia before developing symptoms who should be treated early but are usually reluctant to undergo surgery 4
• Cinacalcet is equally effective in the medical management of PHPT patients across a broad spectrum of disease severity 5
• The efficacy of cinacalcet was maintained for up to 4.5 years of follow-up 5

Efficacy and Safety of Cinacalcet

The efficacy and safety of cinacalcet in primary hyperparathyroidism have been supported by various studies, including:

• A systematic review and meta-analysis of randomized controlled trials and cohort studies, which found that cinacalcet normalizes serum calcium in patients with PHPT and decreases serum PTH levels 7
• A meta-analysis, which found that serum calcium levels normalized in 76% of patients regardless of the duration of treatment, and PTH levels decreased by 13% to 55% 7
• Cinacalcet is safe with tolerable side effects, and the risk of bias was low in most studies 7