What are the treatment options for a patient with primary hyperparathyroidism, elevated Parathyroid Hormone (PTH) levels, and hypercalcemia?

From the Guidelines

The primary treatment for primary hyperparathyroidism with elevated PTH and hypercalcemia is parathyroidectomy, which involves surgical removal of the abnormal parathyroid gland(s), as it is curative in about 95% of cases and is recommended for patients with significant hypercalcemia, such as the patient in question with a calcium level of 10.4 and PTH of 85 1. The treatment options for a patient with primary hyperparathyroidism, elevated Parathyroid Hormone (PTH) levels, and hypercalcemia can be summarized as follows:

• Surgical removal of the abnormal parathyroid gland(s) is the only curative treatment option, with two accepted operative strategies: bilateral neck exploration (BNE) and minimally invasive parathyroidectomy (MIP) 1.
• BNE is a bilateral operation in which all parathyroid glands are identified and examined by the surgeon, who resects the diseased glands, while MIP is a unilateral operation utilizing limited dissection for targeted removal of only the affected gland 1.
• MIP is often performed as it conveys the benefits of shorter operating times, faster recovery, and decreased perioperative costs, but requires confident and precise preoperative localization of a single parathyroid adenoma to guide the surgical approach 1.
• For patients who are poor surgical candidates or refuse surgery, medical management options include cinacalcet, which reduces PTH secretion and lowers calcium levels, and bisphosphonates like alendronate or zoledronic acid to improve bone density 1.
• Regular monitoring of calcium, PTH, kidney function, and bone density is essential for non-surgical patients, and the choice between surgery and medical management should be individualized based on the patient's age, symptoms, comorbidities, and preferences 1. Key considerations in the treatment of primary hyperparathyroidism include:
• The patient's age, symptoms, and comorbidities, such as reduced kidney function, osteoporosis, or kidney stones 1.
• The severity of hypercalcemia, with significant hypercalcemia (>1 mg/dL above normal) being an indication for surgical treatment 1.
• The patient's preferences and values, with surgery offering the only definitive cure by addressing the underlying cause of excessive PTH production 1.

From the FDA Drug Label

1.3 Primary Hyperparathyroidism 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 recommended starting oral dose of cinacalcet tablets is 30 mg twice daily. The dose of cinacalcet tablets should be titrated every 2 to 4 weeks through sequential doses of 30 mg twice daily, 60 mg twice daily, and 90 mg twice daily, and 90 mg 3 or 4 times daily as necessary to normalize serum calcium levels

The treatment options for a patient with primary hyperparathyroidism, elevated Parathyroid Hormone (PTH) levels, and hypercalcemia include cinacalcet. The starting dose is 30 mg twice daily, and the dose should be titrated every 2 to 4 weeks to normalize serum calcium levels.

• Key considerations:
  • Cinacalcet is indicated for patients who are unable to undergo parathyroidectomy.
  • The dose should be titrated to maintain a corrected total serum calcium concentration within the normal range.
  • Serum calcium levels should be monitored frequently during dose titration.
  • The median dose of cinacalcet at the completion of the study was 60 mg/day 2.
• Monitoring:
  • Serum calcium should be measured within 1 week after initiation or dose adjustment of cinacalcet tablets.
  • Serum calcium should be measured approximately every 2 months for patients with primary hyperparathyroidism 2.

From the Research

Treatment Options for Primary Hyperparathyroidism

The treatment options for a patient with primary hyperparathyroidism, elevated Parathyroid Hormone (PTH) levels, and hypercalcemia include:

• Parathyroidectomy, which is the only definitive therapy for primary hyperparathyroidism 3, 4
• Medical management for patients who cannot or do not want to undergo surgery, which may include:
  • Calcium and vitamin D supplementation, with recommended calcium intake following guidelines established for all individuals 3
  • Pharmacological approaches, such as cinacalcet, which can lower serum calcium concentrations and increase bone mineral density (BMD) 3, 5, 6, 7
  • Bisphosphonate therapy, which can improve BMD, with the best evidence for the use of alendronate 3, 5
  • Combination therapy with cinacalcet and bisphosphonates, which may be reasonable but lacks strong evidence for efficacy 3

Medical Management

Medical management of primary hyperparathyroidism can be effective in controlling serum calcium and PTH levels, as well as improving BMD. Cinacalcet, a calcimimetic, has been shown to:

• Reduce serum calcium concentrations to normal in many cases 3, 7
• Have a modest effect on serum PTH levels, with some studies showing a significant decrease in PTH concentrations after 1 year of treatment 7
• Not significantly affect BMD, although combination therapy with bisphosphonates may be beneficial 3, 5

Patient Considerations

When considering treatment options for a patient with primary hyperparathyroidism, it is essential to:

• Evaluate the patient's individual needs and circumstances, including their willingness to undergo surgery and their overall health status
• Monitor serum calcium and PTH levels, as well as BMD, to assess the effectiveness of treatment
• Consider the potential side effects of medical management, such as nausea and vomiting with cinacalcet therapy 7