What is the treatment for hyperparathyroidism?

Treatment of Hyperparathyroidism

Parathyroidectomy is the definitive treatment for primary hyperparathyroidism, especially in symptomatic patients or those with evidence of bone disease, while medical management with calcimimetics, vitamin D supplementation, and phosphate control are first-line treatments for secondary hyperparathyroidism in chronic kidney disease. 1, 2

Types of Hyperparathyroidism and Their Management

Primary Hyperparathyroidism

Surgical Management

• Parathyroidectomy is the treatment of choice with a 95-98% cure rate when performed by an experienced surgeon 2

• Surgical approaches include:

  • Bilateral neck exploration (traditional approach)
  • Minimally invasive parathyroidectomy (MIP) - preferred if preoperative imaging confidently localizes a single adenoma 1
  • Advantages of MIP: shorter operating time, faster recovery, decreased costs

• Surgical indications according to the American Association of Endocrine Surgeons 1:

  • Any fragility fracture
  • Significant bone mineral density reduction
  • Evidence of bone disease
  • History of vertebral fracture
  • Elevated PTH level
  • Renal stones

Medical Management (when surgery is contraindicated)

• Cinacalcet - FDA approved for primary hyperparathyroidism in patients who cannot undergo surgery 3

  • Starting dose: 30 mg twice daily
  • Titrate every 2-4 weeks through sequential doses of 30 mg twice daily, 60 mg twice daily, 90 mg twice daily, and 90 mg 3-4 times daily as needed
  • Monitor serum calcium within 1 week after initiation or dose adjustment

• Antiresorptive medications:

  • Bisphosphonates
  • Estrogens (in postmenopausal women)
  • Selective estrogen receptor modulators 2

• Monitoring if surgery is not performed 1:

  • Serum calcium and PTH every 6 months
  • Bone density testing annually

Secondary Hyperparathyroidism (CKD-related)

Medical Management

• For patients on dialysis:

  • Calcimimetics (Cinacalcet) 3:

    • Starting dose: 30 mg once daily with food
    • Titrate no more frequently than every 2-4 weeks through doses of 30,60,90,120, and 180 mg once daily
    • Target iPTH levels: 150-300 pg/mL
    • Monitor serum calcium frequently during dose titration

  • Vitamin D sterols (calcitriol or vitamin D analogs) 1

  • Phosphate binders to control serum phosphate levels

• For CKD patients not on dialysis:

  • Cinacalcet is NOT indicated due to increased risk of hypocalcemia 3
  • Reserve calcitriol or vitamin D analogs for severe and progressive hyperparathyroidism 1

Surgical Management

• Indications for parathyroidectomy:

  • Severe hyperparathyroidism (PTH >800 pg/mL) refractory to medical therapy 1
  • Calciphylaxis
  • Progressive bone disease

• Surgical options 4:

  • Total parathyroidectomy (TPTX)
  • Total parathyroidectomy with autotransplantation (TPTX+AT)
  • Subtotal parathyroidectomy (SPTX)

• Recent evidence suggests TPTX may have advantages over TPTX+AT in reducing SHPT relapse 4

Tertiary Hyperparathyroidism

• Occurs when parathyroid glands continue to oversecrete PTH despite correction of the primary disorder (typically after renal transplantation) 5
• Primary treatment is surgical - parathyroidectomy 5
• Surgical options include:
  • Total parathyroidectomy with or without autotransplantation
  • Subtotal parathyroidectomy
  • Limited parathyroidectomy

Monitoring and Follow-up

• Primary hyperparathyroidism: Monitor serum calcium every 2 months 3
• Secondary hyperparathyroidism:
  • Initial monitoring: Check serum phosphate, calcium, and PTH every 4 weeks
  • Once stable: Monitor every 3 months 1
  • Adjust dosages based on phosphate, PTH, and calcium levels

Special Considerations

• Hypocalcemia management in secondary hyperparathyroidism 3:

  • If calcium falls below 8.4 mg/dL but remains above 7.5 mg/dL: Increase calcium-containing phosphate binders and/or vitamin D sterols
  • If calcium falls below 7.5 mg/dL: Withhold cinacalcet until calcium reaches 8 mg/dL, then restart at lower dose

• Bone health: Parathyroidectomy for primary hyperparathyroidism improves bone mineral density in up to 75% of patients, with younger patients and those with severe disease deriving the most skeletal benefits 6

• Switching from etelcalcetide to cinacalcet 3:

  • Discontinue etelcalcetide for at least 4 weeks prior to starting cinacalcet
  • Ensure corrected serum calcium is at or above the lower limit of normal
  • Start cinacalcet at 30 mg once daily