What is the first line of treatment for hyperparathyroidism?

From the Guidelines

The first line of treatment for hyperparathyroidism is surgical excision of the abnormally functioning parathyroid tissue, specifically parathyroidectomy, which is typically indicated even in asymptomatic patients due to the potential negative effects of long-term hypercalcemia. This approach is supported by the most recent evidence from the Journal of the American College of Radiology, which emphasizes the importance of surgical treatment for primary hyperparathyroidism (PHPT) 1.

Treatment Options

There are two accepted curative operative strategies for PHPT: bilateral neck exploration (BNE) and minimally invasive parathyroidectomy (MIP) 1.

• BNE is a bilateral operation where all parathyroid glands are identified and examined, and the diseased glands are resected.
• MIP is a unilateral operation that utilizes limited dissection for targeted removal of the affected gland, which is less invasive than BNE and often preferred for patients with a single adenoma.

Considerations

The choice between BNE and MIP depends on various factors, including the presence of a single adenoma, multigland disease, or discordant preoperative imaging results 1.

• For patients with a single adenoma, MIP is often the preferred approach due to its benefits of shorter operating times, faster recovery, and decreased perioperative costs.
• In cases of multigland disease or discordant preoperative imaging, BNE may be necessary to ensure complete removal of the diseased glands.

Medical Management

For asymptomatic patients who do not meet surgical criteria or are poor surgical candidates, medical management may be considered, including bisphosphonates or cinacalcet to lower calcium levels, as well as adequate hydration and a low-calcium diet 1.

• However, surgery remains the preferred treatment option due to its high cure rate and ability to address the underlying cause of the disease.

From the FDA Drug Label

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 The first line of treatment for primary hyperparathyroidism is typically parathyroidectomy, but for patients who are unable to undergo surgery, cinacalcet can be used to treat hypercalcemia.

• The recommended starting oral dose of cinacalcet tablets is 30 mg twice daily for patients with primary hyperparathyroidism.
• The dose of cinacalcet tablets should be titrated every 2 to 4 weeks as necessary to normalize serum calcium levels 2

From the Research

Hyperparathyroidism Treatment

The first line of treatment for hyperparathyroidism depends on the severity of the condition and the presence of symptoms.

• For asymptomatic primary hyperparathyroidism, the treatment approach may vary, but surgery is often considered in certain cases 3.
• According to the study published in 2014, parathyroidectomy is the only definitive therapy for primary hyperparathyroidism, and it is appropriate to consider in all patients 4.
• The study also recommends that patients with low serum 25-hydroxyvitamin D should be repleted with doses of vitamin D, and pharmacological approaches such as cinacalcet and bisphosphonate therapy may be used to control hypercalcemia and improve bone mineral density (BMD) 4.
• For symptomatic primary hyperparathyroidism, surgery is indicated, and parathyroidectomy is the treatment of choice 3, 5.
• In cases where surgery is not possible or desired, medical management with cinacalcet and vitamin D supplementation may be considered 4, 6.
• Alendronate therapy has also been shown to be effective in improving BMD in patients with primary hyperparathyroidism-related osteoporosis 7.

Treatment Options

The treatment options for hyperparathyroidism include:

• Parathyroidectomy: the surgical removal of all hyperfunctional parathyroid tissue 3, 5.
• Cinacalcet: a medication that reduces serum calcium concentrations and is used to control hypercalcemia 4, 6.
• Bisphosphonate therapy: a medication that improves BMD and is used to treat osteoporosis 4, 7.
• Vitamin D supplementation: used to replenish low serum 25-hydroxyvitamin D levels 4.
• Alendronate: a medication that improves BMD and is used to treat osteoporosis 7.