What are the recommendations for pain control in hyperparathyroidism?

Pain Management in Hyperparathyroidism

For patients with hyperparathyroidism, pain management should focus on treating the underlying disease through medical therapy or parathyroidectomy, as surgical intervention is the most effective approach for pain control in cases refractory to medical management. 1

Types of Pain in Hyperparathyroidism

• Musculoskeletal pain: Common in primary and secondary hyperparathyroidism
• Bone pain: Due to increased bone resorption and osteitis fibrosa cystica
• Joint pain: From crystal deposition (calcium pyrophosphate) and arthritis
• Renal colic: From kidney stones

Medical Management Approach

First-Line Treatment: Address Underlying Hyperparathyroidism

1. Primary Hyperparathyroidism:

   • Surgical parathyroidectomy is the definitive treatment for symptomatic cases 1
   • Indications for surgery include:
     • Persistent pain despite medical therapy
     • Serum calcium >1 mg/dL above normal range
     • Osteoporosis
     • Renal complications
     • Age ≤50 years

2. Secondary Hyperparathyroidism:

   • Vitamin D optimization:

     • High-dose cholecalciferol 50,000 IU weekly for 8-12 weeks for deficiency 1
     • Target normal 25-hydroxyvitamin D levels

   • Calcium management:

     • Adjust calcium supplements based on serum levels
     • Monitor serum calcium every 4 weeks initially, then every 3 months 1

   • Phosphate management:

     • Decrease phosphate supplements if PTH levels are elevated 1
     • Avoid doses >80 mg/kg daily of elemental phosphorus 2

   • Active vitamin D analogs:

     • Calcitriol (initial dose 20-30 ng/kg daily) or alfacalcidol (30-50 ng/kg daily) 2
     • Adjust based on PTH response

Pharmacological Pain Management

When pain persists despite addressing the underlying hyperparathyroidism:

1. Non-steroidal anti-inflammatory drugs (NSAIDs):

   • First-line for acute pain flares
   • Caution in renal impairment

2. Calcimimetics (cinacalcet):

   • Consider for persistent secondary hyperparathyroidism 2
   • Starting dose 30 mg once daily with food
   • Monitor for hypocalcemia
   • Not indicated for CKD patients not on dialysis 1

3. Bisphosphonates:

   • Consider for bone pain and to prevent bone loss
   • Useful in primary hyperparathyroidism when surgery is contraindicated

4. Hydroxychloroquine:

   • May help with chronic inflammatory arthritis associated with calcium pyrophosphate deposition 2
   • NNT for clinical response = 2 (95% CI 1 to 7)

Surgical Management

1. Parathyroidectomy:

   • Recommended for severe hyperparathyroidism (PTH >800 pg/mL) with hypercalcemia and/or hyperphosphatemia refractory to medical therapy 1
   • Options include:
     • Subtotal parathyroidectomy
     • Total parathyroidectomy with autotransplantation
   • Surgical choice may depend on likelihood of future kidney transplantation 2

2. Post-surgical monitoring:

   • Monitor calcium levels closely after surgery
   • Be prepared to treat hungry bone syndrome

Special Considerations

1. Calcium Pyrophosphate Deposition (CPPD):

   • Patients with hyperparathyroidism are three times more likely to have CPPD 2
   • Treatment of hyperparathyroidism may improve CPPD-associated arthritis

2. Chronic Kidney Disease:

   • Maintain serum CO2 >22 mEq/L 2
   • Consider calcimimetics for dialysis patients 1

3. Tertiary Hyperparathyroidism:

   • Consider parathyroidectomy for persistent hypercalcemic hyperparathyroidism despite optimized therapy 2

Monitoring Response to Treatment

• Assess pain levels regularly using validated pain scales
• Monitor serum calcium, phosphate, and PTH levels every 4 weeks initially, then every 3 months 1
• Evaluate bone density annually if surgery is not performed 1

By addressing the underlying hyperparathyroidism through appropriate medical or surgical intervention, most patients will experience significant pain relief. For those with persistent symptoms, a targeted approach to pain management based on the specific pain characteristics is recommended.