How are high Parathyroid Hormone (PTH) levels managed?

From the Guidelines

High parathyroid hormone (PTH) levels should be managed based on the underlying cause, with a focus on medical management for secondary hyperparathyroidism due to kidney disease, including phosphate binders and vitamin D analogs, while primary hyperparathyroidism may require surgical removal of the affected gland(s). The management of high PTH levels involves addressing the underlying cause, which can be primary hyperparathyroidism or secondary hyperparathyroidism due to kidney disease. For secondary hyperparathyroidism, medical management is often the first line of treatment, including the use of phosphate binders like sevelamer (800-1600 mg with meals) to reduce phosphate absorption, and vitamin D analogs such as calcitriol (0.25-1 mcg daily) or paricalcitol (1-2 mcg daily) to suppress PTH secretion 1. Some key points to consider in managing high PTH levels include:

• Medical management for secondary hyperparathyroidism due to kidney disease
• Phosphate binders to reduce phosphate absorption
• Vitamin D analogs to suppress PTH secretion
• Dietary modifications, including limiting phosphorus intake and ensuring adequate calcium consumption
• Regular monitoring of calcium, phosphorus, and PTH levels to adjust treatment In cases where medical management is not effective, or in patients with primary hyperparathyroidism, surgical removal of the affected parathyroid gland(s) may be necessary 1. It's also important to note that the choice of surgical approach, such as subtotal parathyroidectomy, total parathyroidectomy, or total parathyroidectomy with autotransplantation, depends on various factors, including the severity of the disease and the patient's overall health status 1. Overall, the goal of managing high PTH levels is to reduce the risk of complications, such as bone disease and cardiovascular disease, and to improve the patient's quality of life.

From the FDA Drug Label

The dose was not increased if a patient had any of the following: iPTH ≤ 200 pg/mL, serum calcium < 7.8 mg/dL, or any symptoms of hypocalcemia. If a patient experienced symptoms of hypocalcemia or had a serum calcium < 8. 4 mg/dL, calcium supplements and/or calcium-based phosphate binders could be increased. If these measures were insufficient, the vitamin D dose could be increased. Approximately 60% of patients with mild (iPTH ≥ 300 to ≤ 500 pg/mL), 41% with moderate (iPTH > 500 to 800 pg/mL), and 11% with severe (iPTH > 800 pg/mL) secondary HPT achieved a mean iPTH value of ≤ 250 pg/mL.

High PTH levels are managed by:

• Cinacalcet (PO): The dose is titrated every 3 or 4 weeks to a maximum dose of 180 mg once daily to achieve an iPTH of ≤ 250 pg/mL.
• Paricalcitol (PO): The dose is individualized and titrated based on iPTH, serum calcium, and phosphorus levels to maintain an iPTH level within the target range.
• Monitoring: Serum calcium and phosphorus levels are closely monitored after initiation of treatment, during dose titration periods, and during co-administration with strong CYP3A inhibitors.
• Dose adjustment: The dose is adjusted based on the patient's response to treatment, with the goal of achieving a stable iPTH level.
• Calcium supplements and/or calcium-based phosphate binders: These may be increased if a patient experiences symptoms of hypocalcemia or has a serum calcium < 8.4 mg/dL.
• Vitamin D dose: The vitamin D dose may be increased if the above measures are insufficient 2, 3.

From the Research

High PTH Levels Management

High Parathyroid Hormone (PTH) levels can be managed through various therapeutic strategies. The following are some of the ways to manage high PTH levels:

• Medications: Cinacalcet HCl, a calcimimetic, can be used to suppress PTH secretion without causing significant hypercalcemia or hyperphosphatemia 4.
• Vitamin D analogs: Paricalcitol, a vitamin D analog, can be effective in reducing PTH concentrations without causing significant hypercalcemia or hyperphosphatemia 5, 6.
• Combination therapy: Combination of paricalcitol and cinacalcet can be used, but it may not provide additional benefits compared to using paricalcitol alone 6.
• Surgery: In cases of tertiary hyperparathyroidism, surgery may be necessary to remove the parathyroid glands 7.

Treatment Outcomes

The treatment outcomes for high PTH levels can vary depending on the therapeutic strategy used. Some of the outcomes include:

• Reduced PTH levels: Cinacalcet HCl and paricalcitol can effectively reduce PTH levels 5, 4, 6.
• Improved bone histology: Cinacalcet HCl can improve bone histology in patients with secondary hyperparathyroidism 8.
• Decreased bone turnover: Cinacalcet HCl can decrease bone turnover and improve mineralized bone volume 8.

Treatment Considerations

When managing high PTH levels, the following considerations should be taken into account:

• Hypercalcemia and hyperphosphatemia: Therapies that can cause hypercalcemia and hyperphosphatemia should be used with caution 5, 4.
• Resistance to treatment: Some patients may become resistant to calcimimetic treatment, and alternative therapies may be necessary 7.
• Surgical complications: Surgical procedures to remove parathyroid glands can have complications, and the most appropriate surgical procedure is still unclear 7.