From the Guidelines
The treatment for hyperparathyroidism is surgical excision of the abnormally functioning parathyroid tissue, which is typically indicated even when asymptomatic, given potential negative effects of long-term hypercalcemia.
Treatment Options
There are two accepted curative operative strategies for primary hyperparathyroidism (PHPT): bilateral neck exploration (BNE) and minimally invasive parathyroidectomy (MIP) 1. 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 defined variably in the literature, but for this context, MIP refers to a unilateral operation utilizing limited dissection for targeted removal of only the affected gland.
Indications for Surgery
Surgery is recommended for patients with significant symptoms, those under 50 years old, with substantially elevated calcium levels (>1 mg/dL above normal), reduced kidney function, osteoporosis, or kidney stones.
Medical Management
For patients who cannot undergo surgery, medical management includes cinacalcet (Sensipar) at doses of 30-90 mg twice daily to lower calcium levels by reducing PTH secretion, or bisphosphonates like alendronate (Fosamax) at 70 mg weekly to prevent bone loss 1.
Secondary Hyperparathyroidism
For secondary hyperparathyroidism (often due to kidney disease), treatment focuses on addressing the underlying cause through vitamin D supplements (calcitriol 0.25-1 mcg daily), phosphate binders like sevelamer (800-1600 mg with meals), and calcimimetics 1.
Key Considerations
Regular monitoring of calcium, phosphorus, and PTH levels is essential for all patients to adjust treatment as needed. Treatment effectiveness is measured by normalization of calcium levels and improvement in symptoms like bone pain, kidney function, and neurological manifestations.
- Important supportive measures include adequate hydration and avoiding thiazide diuretics.
- The choice of surgical approach may depend on the presence of multigland disease (MGD) or other factors, with BNE being necessary in cases of discordant or nonlocalizing preoperative imaging or when there is high suspicion for MGD 1.
- For secondary hyperparathyroidism, total parathyroidectomy (TPTX) may be superior to total parathyroidectomy with autotransplantation (TPTX + AT) in reducing the rate of recurrent SHPT, although this conclusion needs to be tested in large-scale confirmatory trials 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 Cinacalcet tablets are indicated for the treatment of hypercalcemia in adult patients with Parathyroid Carcinoma Cinacalcet tablets are indicated for the treatment of severe hypercalcemia in adult patients with primary HPT who are unable to undergo parathyroidectomy
The treatment for hyperparathyroidism is cinacalcet. The recommended starting oral dose of cinacalcet tablets is:
- 30 mg once daily for secondary hyperparathyroidism in patients with chronic kidney disease on dialysis
- 30 mg twice daily for parathyroid carcinoma and primary hyperparathyroidism The dose of cinacalcet tablets should be titrated every 2 to 4 weeks to target iPTH levels of 150 to 300 pg/mL for secondary hyperparathyroidism, and to normalize serum calcium levels for parathyroid carcinoma and primary hyperparathyroidism 2
From the Research
Treatment Options for Hyperparathyroidism
The treatment for hyperparathyroidism can vary depending on the severity of the condition and the patient's overall health. Some of the treatment options include:
- Parathyroidectomy, which is the surgical removal of one or more parathyroid glands [ 3 ]
- Medical management, which can include calcium and vitamin D supplementation, as well as pharmacological approaches to lower serum calcium levels and improve bone mineral density (BMD) [ 3 ]
- Cinacalcet, which is a medication that can help to reduce serum calcium concentrations and improve BMD [ 3,4 ]
- Bisphosphonate therapy, such as alendronate, which can help to improve BMD [ 3,4 ]
- Combination therapy with cinacalcet and alendronate, which can help to normalize hypercalcemia and improve BMD [ 4 ]
Surgical Treatment
Parathyroidectomy is the only definitive therapy for primary hyperparathyroidism and is appropriate to consider in all patients [ 3 ]. Studies have shown that parathyroidectomy can improve symptoms and quality of life for patients with hyperparathyroidism [ 5 ].
Medical Management
For patients who cannot or do not want to undergo surgery, medical management is an option. This can include calcium and vitamin D supplementation, as well as pharmacological approaches to lower serum calcium levels and improve BMD [ 3 ]. Cinacalcet and bisphosphonate therapy are two medications that have been shown to be effective in managing hyperparathyroidism [ 3,4 ].
Diagnosis and Referral
Hyperparathyroidism is often under-recognized and under-diagnosed [ 6 ]. Studies have shown that machine learning algorithms can be used to improve diagnostic recognition of primary hyperparathyroidism [ 6 ]. It is important for patients with hypercalcemia to be referred for further evaluation and treatment, as hyperparathyroidism is a surgically correctable condition [ 7 ].