From the Guidelines
Treatment for hyperparathyroidism should prioritize surgery (parathyroidectomy) for primary hyperparathyroidism, especially in patients with significant symptoms, bone loss, kidney stones, or substantially elevated calcium levels, as it is the definitive treatment. For primary hyperparathyroidism, the most recent and highest quality study 1 suggests that surgery is the preferred treatment option. This involves the removal of the overactive parathyroid gland(s) and is typically indicated even when asymptomatic, given the potential negative effects of long-term hypercalcemia. There are two accepted curative operative strategies for primary hyperparathyroidism: bilateral neck exploration (BNE) and minimally invasive parathyroidectomy (MIP). BNE refers to a bilateral operation in which all parathyroid glands are identified and examined by the surgeon, who resects the diseased glands. MIP is a unilateral operation utilizing limited dissection for targeted removal of only the affected gland. Some key points to consider in the treatment of hyperparathyroidism include:
- The role of imaging in primary hyperparathyroidism is to localize the abnormally functioning gland or glands with high accuracy and high confidence to facilitate targeted curative surgery.
- For secondary hyperparathyroidism, treatment focuses on addressing the underlying cause, often kidney disease, using vitamin D analogs, phosphate binders, and calcimimetics.
- Regular monitoring of calcium, phosphorus, and parathyroid hormone (PTH) levels is essential to assess treatment effectiveness and adjust therapy accordingly.
- Medical management for primary hyperparathyroidism, when surgery is not an option, includes cinacalcet (Sensipar) to reduce PTH production, and bisphosphonates like alendronate or denosumab to prevent bone loss.
- Supportive measures such as adequate hydration, limiting dietary calcium, and avoiding thiazide diuretics are important for all types of hyperparathyroidism. Overall, the treatment approach should be individualized based on the severity of the condition, the presence of symptoms, and the patient's overall health status, with a focus on improving morbidity, mortality, and quality of life outcomes.
From the FDA Drug Label
Cinacalcet tablets are indicated for the treatment of secondary hyperparathyroidism (HPT) in adult patients with chronic kidney disease (CKD) on dialysis [see Clinical Studies (14. 1)]. 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 options for hyperparathyroidism include:
- Cinacalcet tablets for secondary hyperparathyroidism in adult patients with chronic kidney disease (CKD) on dialysis
- Cinacalcet tablets for hypercalcemia in adult patients with Parathyroid Carcinoma
- Cinacalcet tablets for hypercalcemia in adult patients with primary hyperparathyroidism who are unable to undergo parathyroidectomy The recommended starting oral dose of cinacalcet tablets is 30 mg once daily for secondary hyperparathyroidism in patients with CKD on dialysis, and 30 mg twice daily for patients with Parathyroid Carcinoma and primary hyperparathyroidism 2.
From the Research
Treatment Options for Hyperparathyroidism
The treatment options for hyperparathyroidism can be categorized into surgical and medical management.
- Surgical Management:
- Minimally invasive parathyroidectomy (PTx) is the treatment of choice for symptomatic patients with primary hyperparathyroidism, leading to immediate normalization of hypercalcemia and significant improvement of bone mineral density, cardiovascular dysfunctions, neuropsychological symptoms, and quality of life 3.
- Parathyroidectomy is the only curative therapy for primary hyperparathyroidism, with a high cure rate of 95-98% 4.
- Surgical techniques include bilateral neck exploration, unilateral neck explorations, minimally invasive parathyroidectomies, and minimally invasive radio-guided parathyroidectomy 5.
- Medical Management:
- For patients with secondary hyperparathyroidism, available drugs include non-calcium-containing phosphate binders, calcitriol analogues, calcimimetic agents, or a combination of two or more drugs 3.
- Calcimimetics, such as cinacalcet, can reduce serum levels of parathyroid hormone (PTH) and calcium, and are a potential alternative for patients contraindicated for PTX or who have failed previous PTX and have recurrent primary hyperparathyroidism 6.
- For patients with primary hyperparathyroidism and severe hypercalcemia during the COVID-19 pandemic, pharmacologic management with cinacalcet, bisphosphonates, or denosumab can be used as a temporary measure until parathyroidectomy can be performed safely 7.
Considerations for Specific Patient Groups
- Chronic Kidney Disease (CKD) Patients: Secondary hyperparathyroidism is a common complication in patients with CKD, and calcimimetics have been shown to reduce PTH, calcium, phosphate, and calcium x phosphate product in these patients 6.
- Kidney Transplant Recipients: Tertiary hyperparathyroidism can occur in kidney transplant recipients, and calcimimetics may be a valid alternative to PTX for controlling calcium phosphate metabolism 6.