From the Guidelines
Secondary hyperparathyroidism in chronic kidney disease is primarily managed with phosphate binders, vitamin D analogs, and calcimimetics, with the goal of maintaining parathyroid hormone (PTH) levels within target ranges while minimizing complications. The management of secondary hyperparathyroidism (SHPT) in chronic kidney disease (CKD) involves a multifaceted approach, targeting different aspects of the condition to improve morbidity, mortality, and quality of life.
Key Medications:
- Phosphate binders (calcium-based like calcium carbonate and calcium acetate, or non-calcium based like sevelamer, lanthanum carbonate, and ferric citrate) to control serum phosphate levels.
- Vitamin D analogs (calcitriol, paricalcitol, doxercalciferol) to suppress PTH production, though their use should be reserved for patients with severe and progressive hyperparathyroidism, especially in those with CKD G4 to G5, as suggested by the 2017 KDIGO guidelines 1.
- Calcimimetics (cinacalcet, etelcalcetide) for patients with persistently elevated PTH levels despite initial therapy.
- Calcium supplements when needed, with careful monitoring to avoid hypercalcemia.
Treatment Approach:
Treatment typically begins with phosphate binders to control serum phosphate levels, followed by the addition of vitamin D analogs to suppress PTH production if necessary. Calcimimetics are added for patients with persistently elevated PTH levels despite initial therapy.
Monitoring and Adjustment:
Dosing of these medications is individualized based on lab values, with regular monitoring of calcium, phosphorus, and PTH levels essential for adjusting medication regimens. The goal is to maintain PTH within target ranges while avoiding hypercalcemia, hyperphosphatemia, and other complications that can worsen bone disease and cardiovascular outcomes in CKD patients, as highlighted in studies such as the EVOLVE trial 1.
Surgical Intervention:
In cases where medical management fails, surgical intervention such as parathyroidectomy may be considered, with total parathyroidectomy with autotransplantation (TPTX + AT) being a common approach, though the choice between TPTX + AT and total parathyroidectomy (TPTX) alone depends on various factors including the risk of recurrence and the potential for hypocalcemia, as discussed in systematic reviews and meta-analyses 1.
Guideline Recommendations:
The 2017 KDIGO clinical practice guideline update for the diagnosis, evaluation, prevention, and treatment of CKD-mineral and bone disorder (CKD-MBD) provides recommendations on the use of these medications and the approach to managing SHPT in CKD patients, emphasizing the importance of individualized care and regular monitoring 1.
Overall, the management of SHPT in CKD requires a comprehensive approach, considering the latest evidence and guidelines to optimize patient outcomes.
From the FDA Drug Label
Paricalcitol capsules are indicated in adults and pediatric patients 10 years of age and older for the prevention and treatment of secondary hyperparathyroidism associated with Chronic Kidney Disease (CKD) Stages 3 and 4. Paricalcitol capsules are indicated in adults and pediatric patients 10 years of age and older for the prevention and treatment of secondary hyperparathyroidism associated with CKD Stage 5 in patients on hemodialysis (HD) or peritoneal dialysis (PD). Cinacalcet tablets are indicated for the treatment of secondary hyperparathyroidism (HPT) in adult patients with chronic kidney disease (CKD) on dialysis.
The medications used to manage hyperparathyroidism (Secondary Hyperparathyroidism) caused by Chronic Kidney Disease (CKD) are:
- Paricalcitol (PO): indicated for the prevention and treatment of secondary hyperparathyroidism associated with CKD Stages 3,4, and 5 in patients on hemodialysis (HD) or peritoneal dialysis (PD) 2, 2.
- Cinacalcet (PO): indicated for the treatment of secondary hyperparathyroidism in adult patients with CKD on dialysis 3.
From the Research
Medications for Managing Hyperparathyroidism in CKD
The management of secondary hyperparathyroidism in patients with Chronic Kidney Disease (CKD) involves several medications aimed at reducing parathyroid hormone (PTH) levels, managing calcium and phosphate levels, and preventing bone disease and vascular calcification.
- Vitamin D Analogs: These are used to inhibit PTH gene transcription and parathyroid hyperplasia with reduced calcemic activity compared to calcitriol 4. Examples include paricalcitol, which has been shown to effectively suppress PTH with a lower risk of hypercalcemia compared to calcitriol in some studies 5.
- Calcimimetics: Drugs like cinacalcet are effective in controlling secondary hyperparathyroidism by mimicking calcium on the parathyroid gland, thus reducing PTH secretion 6, 7. Cinacalcet has been found to be effective in non-dialysis patients with CKD and secondary hyperparathyroidism, reducing PTH levels over long-term use 7.
- Phosphate Binders: These are crucial in managing hyperphosphatemia, a key factor in the development of secondary hyperparathyroidism. Both calcium-based and non-calcium-based phosphate binders are used, with the choice depending on the patient's calcium levels and the need to avoid hypercalcemia 4, 6.
- Calcitriol: Although it can be effective, its use is limited by the risk of hypercalcemia and adynamic bone disease 4, 5.
Considerations for Treatment
The choice of medication depends on several factors including the stage of CKD, baseline PTH, calcium, and phosphate levels, as well as the presence of other complications like vascular calcification or bone disease 4, 6, 8.
- Combination Therapy: Using a combination of these medications can be more effective than monotherapy in some cases, allowing for better control of PTH, calcium, and phosphate levels 8.
- Surgical Intervention: In cases where medical management fails to control secondary hyperparathyroidism, parathyroidectomy may be considered, especially in patients with very high PTH levels, severe hypercalcemia, or significant bone disease 8.
Monitoring and Adjustment
Regular monitoring of PTH, calcium, and phosphate levels is essential to adjust the treatment regimen as needed and to minimize the risk of complications such as hypercalcemia, hypocalcemia, or adynamic bone disease 5, 7.