What is the management approach for a patient with hyperparathyroidism (high PTH)?

From the Guidelines

For primary hyperparathyroidism, parathyroidectomy (surgical removal of the affected parathyroid gland) is the definitive treatment, especially for symptomatic patients, those under 50 years old, or those with significantly elevated calcium levels (>1 mg/dL above normal) 1.

Management Approach

The management approach for a patient with hyperparathyroidism (high PTH) depends on the underlying cause, severity of symptoms, and calcium levels.

• For primary hyperparathyroidism, parathyroidectomy is the treatment of choice 1.
• For asymptomatic patients who don't meet surgical criteria, monitoring with regular calcium and PTH measurements is appropriate.
• Medical management includes maintaining adequate hydration, moderate calcium intake (800-1000 mg daily), and avoiding thiazide diuretics.
• Cinacalcet (starting at 30 mg twice daily, titrated as needed) can lower calcium levels by increasing the parathyroid gland's sensitivity to calcium 1.
• Bisphosphonates like alendronate (70 mg weekly) may help preserve bone density.

Secondary Hyperparathyroidism

For secondary hyperparathyroidism due to vitamin D deficiency, supplementation with vitamin D (typically 1000-2000 IU daily) and addressing the underlying cause is essential.

• In kidney disease-related secondary hyperparathyroidism, phosphate binders (calcium acetate, sevelamer), vitamin D analogs (calcitriol 0.25-1 mcg daily), and calcimimetics like cinacalcet are used to normalize calcium-phosphate metabolism 1.

Surgical Options

Surgical treatment of secondary hyperparathyroidism has been used for more than 50 years, and currently available options include subtotal parathyroidectomy (SPTX), total parathyroidectomy (TPTX), and total parathyroidectomy with autotransplantation (TPTX + AT) 1.

• TPTX + AT has become the first choice for the treatment of SHPT in many clinical centers 1.

Monitoring

Regular monitoring of calcium, phosphate, PTH, and vitamin D levels is crucial for all patients to guide therapy adjustments 1.

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)]. The recommended starting oral dose of cinacalcet tablets is 30 mg once daily. 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.

The management approach for a patient with hyperparathyroidism (high PTH) includes the use of cinacalcet tablets. The treatment should be initiated at a dose of 30 mg once daily and titrated every 2 to 4 weeks to target iPTH levels of 150 to 300 pg/mL. The dose can be increased sequentially to 60,90,120, and 180 mg once daily as necessary. It is essential to monitor serum calcium and serum phosphorus levels within 1 week and intact parathyroid hormone (iPTH) levels 1 to 4 weeks after initiation or dose adjustment of cinacalcet tablets 2.

From the Research

Management Approach for High PTH

The management approach for a patient with hyperparathyroidism (high PTH) depends on the underlying cause and severity of the condition.

• Primary hyperparathyroidism is often caused by a single parathyroid adenoma, and treatment typically involves partial or full parathyroidectomy to correct the underlying condition 3.
• Secondary hyperparathyroidism is commonly caused by chronic kidney disease-mineral and bone disorder (CKD-MBD), and treatment usually involves medical management with phosphate binders, vitamin D analogs, and calcimimetics 3, 4.
• In some cases, secondary hyperparathyroidism may be caused by severe calcium or vitamin D deficiency, and treatment involves calcium and vitamin D replacement 3.
• Cinacalcet, a calcimimetic agent, has been shown to be effective in reducing PTH levels and improving biochemical parameters in patients with secondary hyperparathyroidism 4, 5.
• The dose of vitamin D can be adjusted to maximize reductions in PTH, phosphorus, and calcium, but vitamin D-induced decreases in PTH need to be balanced with the diminished response in phosphorus and calcium 5.
• Cinacalcet may also be used as a medical treatment for primary hyperparathyroidism in certain patient subgroups, such as those with hyperplasia in all glands or those who are unwilling or unable to undergo surgery 6.

Treatment Considerations

• Patients with primary hyperparathyroidism may require surgery, while those with secondary hyperparathyroidism may require medical management with phosphate binders, vitamin D analogs, and calcimimetics.
• The use of cinacalcet and vitamin D should be carefully monitored to avoid adverse effects and to optimize treatment outcomes.
• Patients with secondary hyperparathyroidism due to CKD-MBD may require ongoing medical management to control PTH levels and prevent complications.
• The management approach for high PTH should be individualized based on the underlying cause and severity of the condition, as well as the patient's overall health status and medical history.