What is the management of hyperparathyroidism?

Management of Hyperparathyroidism

The management of hyperparathyroidism should be tailored to the specific type (primary, secondary, or tertiary) with surgical intervention being the definitive treatment for primary hyperparathyroidism, while medical therapy is appropriate for secondary hyperparathyroidism in chronic kidney disease patients.

Types of Hyperparathyroidism and Their Management

Primary Hyperparathyroidism (PHPT)

• Surgical Management:

  • Parathyroidectomy is the only definitive therapy for PHPT and should be considered in all patients 1
  • Minimally invasive parathyroidectomy is increasingly used with excellent outcomes 2

• Medical Management (for non-surgical candidates):

  • Calcium intake: Should follow guidelines established for all individuals; calcium restriction is not recommended 1
  • Vitamin D repletion: For patients with low serum 25-hydroxyvitamin D, supplement to achieve levels ≥50 nmol/L (20 ng/mL), with a goal of ≥75 nmol/L (30 ng/mL) 1
  • Pharmacological options:
    • Cinacalcet: Treatment of choice for controlling hypercalcemia; reduces serum calcium to normal in many cases but has modest effect on PTH levels and does not improve BMD 1, 3
    • Bisphosphonates: Recommended to improve BMD, particularly alendronate, which improves lumbar spine BMD without altering serum calcium 1
    • Combination therapy: Using both cinacalcet and bisphosphonates may reduce serum calcium and improve BMD 1

Secondary Hyperparathyroidism (SHPT)

• Management in Chronic Kidney Disease (CKD):

  • Target PTH levels vary by CKD stage: 4

    • CKD G3: <70 pg/mL
    • CKD G4: <110 pg/mL
    • CKD G5 (non-dialysis): <300 pg/mL
    • CKD G5D (dialysis): 150-600 pg/mL (2-9× upper normal limit)

  • Dietary management:

    • Restrict dietary phosphate intake 4
    • Use phosphate binders, preferably non-calcium based, to target normal phosphate levels 4

  • Pharmacological management:

    • Vitamin D analogs: Calcitriol is indicated for SHPT in both predialysis patients (CrCl 15-55 mL/min) and dialysis patients 5, 6
    • Calcimimetics: Cinacalcet is indicated for SHPT in adult CKD patients on dialysis 3
      • Important limitation: Not indicated for CKD patients not on dialysis due to increased risk of hypocalcemia 3

  • Monitoring:

    • Monitor calcium and phosphorus every 6-12 months in stable patients, more frequently when adjusting therapy 4
    • CKD G3a-G3b: Check PTH, calcium, phosphate every 6-12 months 4

Tertiary Hyperparathyroidism (THPT)

• Definition: Persistent hyperparathyroidism after correction of the primary disorder (typically after renal transplantation) 7, 8

• Management:

  • Surgical intervention: Primary treatment for persistent hypercalcemia and/or increased PTH 7

    • Options include:
      • Total parathyroidectomy with or without autotransplantation
      • Subtotal parathyroidectomy
      • Limited parathyroidectomy
    • Important to remove superior parts of thymus as well 7

  • Medical management:

    • Limited data on effectiveness compared to surgery 8
    • May include calcimimetics and bisphosphonates in patients who cannot undergo surgery

Special Considerations

• Parathyroid Carcinoma:

  • Cinacalcet is indicated for hypercalcemia in adult patients with parathyroid carcinoma 3
  • Surgical management is preferred when possible

• Genetic Syndromes:

  • For carriers of pathogenic germline variants in CDC73 (HPT-JT syndrome), surveillance should begin at age 5-10 years 9
  • Annual biochemical screening for hyperparathyroidism (total calcium, corrected for serum albumin) 9
  • Biopsy of suspicious neck lesions should be avoided due to risk of seeding carcinomatous cells 9

• Complications to monitor:

  • Overcorrection of PTH can lead to adynamic bone disease (PTH <100 pg/mL) 4
  • Hypercalcemia requires close monitoring, particularly when using vitamin D analogs 4

Common Pitfalls and Caveats

1. Failure to distinguish between types of hyperparathyroidism - Each type requires different management approaches
2. Inappropriate use of cinacalcet - Not indicated for non-dialysis CKD patients
3. Inadequate vitamin D repletion - Essential in all types of hyperparathyroidism
4. Delaying surgical referral - Surgery remains the definitive treatment for primary hyperparathyroidism and tertiary hyperparathyroidism
5. Focusing on PTH levels alone - Treatment decisions should consider calcium, phosphorus, and PTH together