What is the treatment for hyperparathyroidism (high parathyroid hormone levels)?

Treatment of Hyperparathyroidism

Parathyroidectomy is the definitive treatment for hyperparathyroidism, especially in cases with severe hyperparathyroidism (PTH >800 pg/mL) that is refractory to medical therapy, with a 95-98% cure rate when performed by an experienced surgeon. 1

Types of Hyperparathyroidism and Their Management

Primary Hyperparathyroidism

Surgical Management

• Indications for surgery:

  • Symptomatic disease
  • Age 50 years or younger
  • Serum calcium >1 mg/dL above upper limit of normal
  • Osteoporosis
  • Creatinine clearance <60 mL/min/1.73m²
  • Nephrolithiasis or nephrocalcinosis
  • Hypercalciuria 2

• Surgical approaches:

  • Minimally invasive parathyroidectomy (MIP): Preferred when preoperative imaging confidently localizes a single adenoma
  • Bilateral neck exploration (BNE): Used when imaging is discordant or non-localizing, or if multigland disease is suspected 1

Medical Management (when surgery is contraindicated or refused)

1. Cinacalcet:

   • FDA-approved for primary hyperparathyroidism in patients who cannot undergo surgery
   • Starting dose: 30 mg twice daily
   • Titrate every 2-4 weeks as needed to normalize serum calcium 3

2. Vitamin D management:

   • Correct vitamin D deficiency with high-dose cholecalciferol (50,000 IU weekly for 8-12 weeks) 1

3. Antiresorptive medications:

   • Bisphosphonates, estrogens, or selective estrogen receptor modulators may help control symptoms 4

Secondary Hyperparathyroidism (in Chronic Kidney Disease)

Surgical Management

• Indications for parathyroidectomy:

  • PTH levels persistently >800 pg/mL
  • Hypercalcemia/hyperphosphatemia refractory to medical therapy
  • Progressive bone disease with pain
  • Calciphylaxis 1

• Surgical options:

  • Total parathyroidectomy (TPTX)
  • Total parathyroidectomy with autotransplantation (TPTX+AT)
  • Subtotal parathyroidectomy (SPTX) 5

Medical Management

1. Cinacalcet:

   • Starting dose: 30 mg once daily
   • Titrate no more frequently than every 2-4 weeks through sequential doses of 30,60,90,120, and 180 mg once daily
   • Target iPTH: 150-300 pg/mL 3

2. Vitamin D analogs:

   • Active vitamin D (calcitriol) to reverse high-turnover bone disease
   • Adjust dosage based on PTH levels 1

3. Phosphate control:

   • Phosphate binders to control serum phosphate levels
   • Calcium-containing phosphate binders can help manage both phosphate and calcium 1

Monitoring and Follow-up

For Surgical Patients

• Post-parathyroidectomy:
  • Check ionized calcium every 4-6 hours for first 48-72 hours
  • Initiate calcium gluconate infusion if calcium drops below normal
  • Transition to oral calcium carbonate and calcitriol as appropriate 1

For Medical Management

• Primary hyperparathyroidism:

  • Monitor serum calcium and PTH every 6 months
  • Annual bone density testing 1

• Secondary hyperparathyroidism (dialysis patients):

  • Initial monitoring: Check serum phosphate, calcium, and PTH every 4 weeks
  • Once stable: Monitor every 3 months
  • For patients on cinacalcet: Monitor serum calcium frequently during dose titration 1

Hypocalcemia Management

• If calcium falls below 8.4 mg/dL but remains above 7.5 mg/dL:

  • Increase calcium-containing phosphate binders
  • Increase vitamin D sterols 1, 3

• If calcium falls below 7.5 mg/dL:

  • Withhold cinacalcet until serum calcium reaches 8 mg/dL
  • Restart at a lower dose 3

Special Considerations

• Pregnancy: Consider treating with active vitamin D and phosphate supplements if needed 1

• Hypophosphatemia: Moderate hypophosphatemia in primary hyperparathyroidism may warrant surgical intervention even in otherwise asymptomatic patients 1

• Non-surgical ablative options: For patients with absolute contraindications to surgery, consider:

  • Selective percutaneous ethanol injection
  • Transcatheter ablation of pathological parathyroid tissue 4

By following this treatment algorithm based on the type of hyperparathyroidism and patient-specific factors, optimal management can be achieved to reduce morbidity and mortality associated with this condition.