How to manage mild elevation of Parathyroid Hormone (PTH) with normal calcium levels?

From the Guidelines

Mild elevation of parathyroid hormone (PTH) with normal calcium levels should be managed by ensuring adequate vitamin D levels and calcium intake, as well as lifestyle modifications, without immediate indication for surgery. The management of mild PTH elevation with normal calcium levels, also known as normocalcemic hyperparathyroidism, involves a conservative approach that focuses on addressing underlying causes and preventing progression to more severe disease.

• Ensuring adequate vitamin D levels is crucial, and supplementation with vitamin D3 1000-2000 IU daily may be necessary if levels are below 30 ng/mL 1.
• Maintaining adequate calcium intake through diet (1000-1200 mg daily) or supplements if dietary intake is insufficient is also important, and calcium supplements should be taken as equally divided doses, with calcium carbonate taken with food and calcium citrate taken with or without food 1.
• Regular weight-bearing exercise and limiting alcohol and caffeine consumption are important lifestyle modifications.
• Monitoring kidney function and avoiding thiazide diuretics, which can increase calcium levels, are also recommended.
• Follow-up with periodic measurements of calcium, PTH, and vitamin D levels every 6-12 months to track any changes, and bone density testing to assess for bone loss, are essential components of management. This approach is supported by the most recent and highest quality study, which emphasizes the importance of addressing underlying causes and preventing progression to more severe disease 1.
• The use of combined vitamin D and calcium supplements may be considered if PTH is raised despite adequate serum 25-hydroxyvitamin D levels and normal calcium levels 1.
• The choice of calcium supplement, such as calcium citrate, may be preferred for people at risk of developing kidney stones 1. Overall, the management of mild PTH elevation with normal calcium levels requires a comprehensive approach that addresses underlying causes, prevents progression to more severe disease, and prioritizes lifestyle modifications and monitoring.

From the FDA Drug Label

The recommended starting oral dose of cinacalcet tablets is 30 mg once daily. Serum calcium and serum phosphorus should be measured within 1 week and intact parathyroid hormone (iPTH) should be measured 1 to 4 weeks after initiation or dose adjustment of cinacalcet tablets. Cinacalcet tablets should be titrated no more frequently than every 2 to 4 weeks through sequential doses of 30,60,90,120, and 180 mg once daily to target iPTH levels of 150 to 300 pg/mL.

For managing mild elevation of Parathyroid Hormone (PTH) with normal calcium levels, the dose of cinacalcet should be titrated to target iPTH levels of 150 to 300 pg/mL.

• Key considerations:
  • Monitor serum calcium levels frequently during dose titration.
  • If serum calcium levels decrease below the normal range, take steps to increase serum calcium levels, such as providing supplemental calcium or initiating/increasing the dose of calcium-based phosphate binders or vitamin D sterols.
  • Withhold treatment with cinacalcet if serum calcium levels fall below 7.5 mg/dL or if symptoms of hypocalcemia persist. 2 2

From the Research

Management of Mild Elevation of Parathyroid Hormone (PTH) with Normal Calcium Levels

• The management of mild elevation of PTH with normal calcium levels can be challenging, and there are several treatment options available 3, 4, 5, 6, 7.
• Cinacalcet, a calcimimetic agent, has been shown to be effective in reducing PTH levels in patients with primary and secondary hyperparathyroidism 3, 4, 6, 7.
• In patients with primary hyperparathyroidism, cinacalcet has been shown to normalize serum calcium levels in most patients, while only modestly reducing serum PTH levels 3.
• In patients with secondary hyperparathyroidism, cinacalcet has been shown to decrease serum intact PTH levels in a dose-dependent manner, and also decrease serum calcium, phosphorus, and calcium-phosphorus product levels 4.
• The addition of cholecalciferol to cinacalcet and calcitriol therapy has been shown to additively reduce serum PTH levels in patients with severe secondary hyperparathyroidism 5.
• Cinacalcet has also been shown to be effective in normalizing calcium and phosphorus concentrations in patients with persistent primary hyperparathyroidism after unsuccessful parathyroidectomy 7.

Treatment Options

• Cinacalcet: a calcimimetic agent that activates the calcium-sensing receptor on the surface of parathyroid cells and inhibits PTH secretion 3, 4, 6, 7.
• Cholecalciferol: a nutritional vitamin D that can be used in combination with cinacalcet and calcitriol to reduce serum PTH levels 5.
• Calcitriol: an active vitamin D analog that can be used in combination with cinacalcet to reduce serum PTH levels 5.

Key Considerations

• The treatment of mild elevation of PTH with normal calcium levels should be individualized based on the patient's underlying condition and medical history 3, 4, 5, 6, 7.
• The use of cinacalcet and other treatment options should be monitored closely to avoid adverse effects such as hypocalcemia and gastrointestinal disorders 4.