From the Guidelines
The treatment for hypercalcemia with elevated intact Parathyroid Hormone (PTH) is primarily surgical removal of the abnormal parathyroid gland(s) through parathyroidectomy, as it addresses the root cause of the condition. This approach is supported by the most recent and highest quality evidence, which prioritizes morbidity, mortality, and quality of life as outcomes.
For patients who are poor surgical candidates or who decline surgery, medical management options can be considered. These may include:
- Bisphosphonates like alendronate (70 mg orally weekly) or zoledronic acid (5 mg IV yearly) to reduce bone resorption
- Cinacalcet (starting at 30 mg twice daily, titrated as needed) which directly lowers PTH secretion by activating calcium-sensing receptors, as discussed in 1 and 1 Adequate hydration is essential in all patients, and dietary calcium should not be restricted but maintained at normal levels (800-1000 mg daily). Vitamin D deficiency should be corrected if present, but supplementation should be done cautiously to avoid worsening hypercalcemia. Regular monitoring of serum calcium, PTH, renal function, and bone density is necessary for all patients.
It's worth noting that the use of cinacalcet has been evaluated in several studies, including 1, which found that it provides small reductions in the risk of surgical parathyroidectomy but has little or no effect on all-cause mortality and uncertain effects on cardiovascular death for people with CKD. However, the most recent and highest quality evidence should be prioritized when making treatment decisions.
In the context of chronic kidney disease, guidelines such as those outlined in 1 and 1 provide recommendations for the management of hyperparathyroidism, including the use of parathyroidectomy in patients with severe hyperparathyroidism. These guidelines emphasize the importance of individualized treatment approaches and regular monitoring of patients with hyperparathyroidism.
Overall, the treatment of hypercalcemia with elevated intact PTH requires a comprehensive approach that takes into account the underlying cause of the condition, as well as the patient's overall health status and medical history. Surgical removal of the abnormal parathyroid gland(s) through parathyroidectomy is the definitive treatment for most patients with symptomatic disease or those meeting surgical criteria, and medical management options should be used judiciously in patients who are poor surgical candidates or who decline surgery.
From the FDA Drug Label
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 hypercalcemia with elevated intact Parathyroid Hormone (PTH) is cinacalcet.
- The recommended starting oral dose of cinacalcet tablets is 30 mg twice daily for patients with Parathyroid Carcinoma and Primary Hyperparathyroidism.
- 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 2.
From the Research
Treatment for Hypercalcemia with Elevated Intact Parathyroid Hormone (PTH)
The treatment for hypercalcemia with elevated intact PTH depends on the severity of the condition and the underlying cause.
- For mild hypercalcemia, observation may be appropriate, especially in patients older than 50 years with serum calcium levels less than 1 mg above the upper normal limit and no evidence of skeletal or kidney disease 3.
- For symptomatic or severe hypercalcemia, initial therapy consists of hydration and intravenous bisphosphonates, such as zoledronic acid or pamidronate 3, 4, 5, 6.
- In patients with primary hyperparathyroidism (PHPT), parathyroidectomy may be considered depending on age, serum calcium level, and kidney or skeletal involvement 3, 7, 5, 6.
- Denosumab can be used as a bridge to surgery in patients with severe hypercalcemia due to PHPT, especially when immediate surgery is not feasible 7.
- Glucocorticoids may be used as primary treatment when hypercalcemia is due to excessive intestinal calcium absorption (vitamin D intoxication, granulomatous disorders, some lymphomas) 3, 4.
Special Considerations
- In patients with kidney failure, denosumab and dialysis may be indicated 3, 4.
- The use of loop diuretics may be required in individuals with renal insufficiency or heart failure to prevent fluid overload 4.
- Calcitonin is administered for the immediate short-term management of severe symptomatic hypercalcemia 4, 6.