From the Guidelines
Surgery, specifically parathyroidectomy, is the definitive treatment for primary hyperparathyroidism, involving removal of the overactive parathyroid gland(s), as it has a high success rate and typically resolves calcium and parathyroid hormone abnormalities 1.
Treatment Overview
The treatment of primary hyperparathyroidism (PHPT) is primarily surgical, with two accepted curative operative strategies: bilateral neck exploration (BNE) and minimally invasive parathyroidectomy (MIP) 1. BNE involves a bilateral operation where all parathyroid glands are identified and examined, and the diseased glands are resected. MIP, on the other hand, is a unilateral operation that utilizes limited dissection for targeted removal of only the affected gland, requiring confident and precise preoperative localization of a single parathyroid adenoma and intraoperative PTH monitoring to confirm removal of the hyperfunctioning gland 1.
Surgical Approach
Given that most patients with PHPT have a single adenoma, directed MIP is often performed due to its benefits of shorter operating times, faster recovery, and decreased perioperative costs 1. However, BNE remains the necessary method in cases of discordant or nonlocalizing preoperative imaging or when there is a high suspicion for multigland disease (MGD) 1.
Importance of Imaging
Imaging plays a crucial role in PHPT to localize the abnormally functioning gland or glands with high accuracy and confidence to facilitate targeted curative surgery 1. It is essential for preoperative planning, especially in the reoperative setting, to identify postoperative changes from previous parathyroid explorations that can impact subsequent surgery 1.
Medical Management
For patients who cannot undergo surgery, medical management may include medications such as cinacalcet to reduce parathyroid hormone production, and bisphosphonates like alendronate to manage bone loss, along with supportive measures like adequate hydration and avoiding thiazide diuretics 1. However, surgery remains the definitive treatment for achieving a cure and preventing long-term complications associated with untreated PHPT, such as osteoporosis, kidney stones, cardiovascular complications, and neuropsychiatric symptoms 1.
From the FDA Drug Label
1.3 Primary Hyperparathyroidism 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)]. 2.3 Patients with Parathyroid Carcinoma and Primary Hyperparathyroidism The recommended starting oral dose of cinacalcet tablets is 30 mg twice daily. The dose of cinacalcet tablets should be titrated every 2 to 4 weeks through sequential doses of 30 mg twice daily, 60 mg twice daily, and 90 mg twice daily, and 90 mg 3 or 4 times daily as necessary to normalize serum calcium levels
The treatment for primary hyperparathyroidism is cinacalcet tablets, which are indicated for the treatment of hypercalcemia in adult patients with primary HPT for whom parathyroidectomy would be indicated but who are unable to undergo it. The recommended starting dose is 30 mg twice daily, with titration every 2 to 4 weeks as necessary to normalize serum calcium levels 2.
From the Research
Treatment Options for Primary Hyperparathyroidism
The treatment for primary hyperparathyroidism (PHPT) includes:
- Parathyroidectomy, which is currently the only curative treatment for PHPT 3, 4, 5, 6
- Cinacalcet, a drug that can be used to reduce serum calcium levels in patients who are ineligible for or unwilling to undergo surgery, or in whom parathyroidectomy has failed 3, 7
Surgical Techniques
Surgical techniques for treating PHPT include:
- Bilateral neck exploration (BNE), which is considered the gold standard procedure in parathyroid surgery 4, 6
- Minimally invasive parathyroidectomy (MIP), which is a standard treatment option in selected patients with positive imaging 4
- Unilateral neck explorations, minimally invasive radio-guided parathyroidectomy, and endoscopic or robotic parathyroidectomy methods 4, 6
Cinacalcet Treatment
Cinacalcet has been found to be effective in: