What is the treatment approach for bone pain related to hyperparathyroidism?

From the Guidelines

The primary treatment for bone pain related to hyperparathyroidism is parathyroidectomy, which addresses the root cause by normalizing calcium and parathyroid hormone levels. This approach is supported by the most recent and highest quality study, which emphasizes the importance of surgical excision of the abnormally functioning parathyroid tissue in treating primary hyperparathyroidism (PHPT) 1. For symptomatic management before surgery or in patients who cannot undergo surgery, bisphosphonates like alendronate (70mg weekly) or zoledronic acid (5mg IV annually) can reduce bone pain by inhibiting bone resorption.

Some key points to consider in the treatment approach include:

• The role of imaging in PHPT is to localize the abnormally functioning gland or glands with high accuracy and high confidence to facilitate targeted curative surgery 1.
• Parathyroidectomy can be performed through bilateral neck exploration (BNE) or minimally invasive parathyroidectomy (MIP), with MIP being less invasive and often preferred for patients with a single adenoma 1.
• In cases of secondary hyperparathyroidism, total parathyroidectomy with autotransplantation (TPTX + AT) has been shown to be an effective treatment option, although the choice of surgical approach may depend on various factors, including the patient's overall health and the severity of the disease 1.
• Regular monitoring of calcium, phosphate, and parathyroid hormone levels is essential to guide treatment adjustments and prevent complications such as hypercalcemia and hypocalcemia.

Overall, the treatment approach for bone pain related to hyperparathyroidism should prioritize parathyroidectomy as the primary treatment, with symptomatic management and monitoring of hormone levels playing important supporting roles.

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 approach for bone pain related to hyperparathyroidism involves the use of cinacalcet to manage hyperparathyroidism and hypercalcemia. The recommended starting dose 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.

• The dose of cinacalcet should be titrated every 2 to 4 weeks to target iPTH levels and normalize serum calcium levels.
• 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 2.
• Patients should be monitored for hypocalcemia, and calcium-containing phosphate binders and/or vitamin D sterols can be used to raise serum calcium if necessary 2.

From the Research

Treatment Approach for Bone Pain Related to Hyperparathyroidism

The treatment approach for bone pain related to hyperparathyroidism involves a combination of medical management and surgical intervention.

• Medical management includes the use of bisphosphonates, such as alendronate, to improve bone mineral density and reduce bone pain 3, 4.
• Cinacalcet is also used to control hypercalcemia, whereas bisphosphonates or denosumab are used to improve bone mineral density 5.
• Combined therapy with cinacalcet and bisphosphonates or cinacalcet and denosumab may be considered when the effects on serum calcium and bone mineral density are simultaneously desired 5.
• Surgical intervention, such as parathyroidectomy, is the only curative therapy for primary hyperparathyroidism and can help prevent fractures 6.

Bone Pain and Hyperparathyroidism

Bone pain is a common symptom of hyperparathyroidism, with studies showing that:

• Back pain, generalized bone pain, and rib cage/chest pain are common musculoskeletal manifestations of primary hyperparathyroidism 7.
• Bone manifestations, such as pseudoclubbing and giant cell tumor of the mandible, can also occur 7.
• Fracture risk is elevated in patients with primary hyperparathyroidism, particularly before diagnosis 6.

Management of Hyperparathyroidism

The management of hyperparathyroidism involves:

• Monitoring and remote medical follow-up of patients with primary hyperparathyroidism and severe hypercalcemia 5.
• Appropriate use of pharmacologic management, such as cinacalcet and bisphosphonates, to control hypercalcemia and improve bone mineral density 5.
• Consideration of surgical intervention, such as parathyroidectomy, as the only curative therapy for primary hyperparathyroidism 6.