What is the protocol for managing high Parathyroid Hormone (PTH) levels?

From the Guidelines

The most effective protocol for managing high Parathyroid Hormone (PTH) levels is total parathyroidectomy (TPTX), as it has been shown to reduce the incidence of various complications of chronic kidney disease (CKD), such as stroke and cardiovascular and all-cause mortality 1.

Key Considerations

• The choice of surgical approach is crucial in the management of high PTH levels, with TPTX being a preferred option due to its ability to quickly relieve electrolyte disorders and reduce the incidence of complications associated with CKD.
• Medical management, including cinacalcet, vitamin D supplementation, and bisphosphonates, may be used for patients who are not surgical candidates or as an adjunct to surgical therapy.
• For secondary hyperparathyroidism due to kidney disease, treatment includes phosphate binders, active vitamin D analogs, and calcimimetics, in addition to dietary modifications and regular monitoring of calcium, phosphorus, vitamin D, and PTH levels.

Surgical Options

• Total parathyroidectomy (TPTX) has been shown to be an effective surgical option for managing high PTH levels, with advantages over subtotal parathyroidectomy (SPTX) and total parathyroidectomy with autotransplantation (TPTX + AT) in reducing the relapse of secondary hyperparathyroidism (SHPT) 1.
• TPTX + AT may be considered in certain cases, but its use is limited due to concerns about complications such as persistent hypocalcemia, permanent hypoparathyroidism, and adynamic bone diseases.

Medical Management

• Cinacalcet, starting at 30mg daily and titrating up to 90mg if needed, may be used to reduce PTH secretion in patients who are not surgical candidates or as an adjunct to surgical therapy.
• Adequate vitamin D supplementation, typically 1,000-2,000 IU daily, is important to prevent deficiency and worsen hyperparathyroidism.
• Bisphosphonates, such as alendronate (70mg weekly) or zoledronic acid (5mg IV annually), may be used to prevent bone loss in patients with high PTH levels.

From the FDA Drug Label

The maintenance dose of PARSABIV is individualized and determined by titration based on parathyroid hormone (PTH) and corrected serum calcium response. Increase the dose of PARSABIV in 2.5 mg or 5 mg increments in individuals with corrected serum calcium within the normal range and PTH levels above the recommended target range based on the patient's PTH levels no more frequently than every 4 weeks up to a maximum dose of 15 mg three times per week. Decrease or temporarily discontinue PARSABIV dosing in individuals with PTH levels below the target range.

The protocol for managing high PTH levels involves:

• Titration of the PARSABIV dose based on PTH and corrected serum calcium response
• Increasing the dose of PARSABIV in 2.5 mg or 5 mg increments if PTH levels are above the target range and corrected serum calcium is within the normal range
• Decreasing or temporarily discontinuing PARSABIV dosing if PTH levels are below the target range 2

From the Research

Protocol for Managing High Parathyroid Hormone (PTH) Levels

The management of high PTH levels, also known as secondary hyperparathyroidism, involves several strategies to minimize the effects of PTH on bone and other tissues. The following are some of the key components of the protocol:

• Vitamin D analogs: Vitamin D analogs, such as paricalcitol and doxercalciferol, are effective in suppressing PTH levels with lesser effects on calcium and phosphorus metabolism 3.
• Vitamin D receptor activators: Vitamin D receptor activators, such as paricalcitol, can achieve control of hyperparathyroidism with a wider therapeutic window than calcitriol 4.
• Nutritional vitamin D: Nutritional vitamin D, such as ergocalciferol, cholecalciferol, and calcifediol, is suggested as first-line therapy to treat secondary hyperparathyroidism with low 25(OH)D insufficiency 5.
• Phosphate control: Phosphate oral intake control, including diet and phosphate binders, is an important aspect of managing secondary hyperparathyroidism 4.
• Calcium intake: Adequate calcium oral intake is also essential in managing secondary hyperparathyroidism 4.

Treatment Options

The treatment options for secondary hyperparathyroidism include:

• Vitamin D receptor activators: Paricalcitol and doxercalciferol are examples of vitamin D receptor activators that can be used to manage secondary hyperparathyroidism 3, 4.
• Nutritional vitamin D: Ergocalciferol, cholecalciferol, and calcifediol are examples of nutritional vitamin D that can be used to manage secondary hyperparathyroidism 5.
• Surgical management: In some cases, surgical management may be necessary to control secondary hyperparathyroidism 6.

Monitoring and Follow-up

Regular monitoring of PTH levels, calcium, and phosphorus is essential to adjust the treatment protocol as needed. The optimal PTH target level for CKD and dialysis patients is still debated, and further research is needed to determine the best approach 7.