From the Guidelines
The next step for a patient with multiple vertebral fractures and primary hyperparathyroidism diagnosed after 10 months of Evenity (romosozumab) treatment is to discontinue Evenity and refer the patient for parathyroidectomy, as primary hyperparathyroidism should be addressed surgically as the definitive treatment, given its role in causing bone loss and increasing fracture risk 1.
Key Considerations
- Primary hyperparathyroidism leads to abnormal calcium metabolism, which can interfere with the effectiveness of bone-forming agents like Evenity and potentially worsen hypercalcemia.
- The American College of Physicians recommends bisphosphonates as the initial pharmacologic treatment for primary osteoporosis to reduce the risk of fractures, with a strong recommendation and high-certainty evidence 1.
- While awaiting surgery, transitioning the patient to an antiresorptive medication such as a bisphosphonate (e.g., alendronate 70mg weekly) or denosumab (60mg subcutaneously every 6 months) can help prevent rapid bone loss after stopping Evenity.
Management Approach
- Discontinue Evenity to avoid potential worsening of hypercalcemia and to prepare the patient for surgical intervention.
- Refer the patient for parathyroidectomy as the definitive treatment for primary hyperparathyroidism.
- Monitor calcium levels closely and optimize vitamin D supplementation to maintain levels above 30 ng/mL, avoiding calcium supplementation if the patient has hypercalcemia.
- After successful parathyroidectomy and normalization of parathyroid hormone levels, reassess osteoporosis treatment based on fracture risk, considering the recommendations for pharmacologic treatment of primary osteoporosis or low bone mass to prevent fractures in adults 1.
From the Research
Management of Primary Hyperparathyroidism
The next step in managing a patient with multiple vertebral fractures and primary hyperparathyroidism diagnosed after 10 months of treatment with Evenity (romosozumab) involves several considerations:
- Surgical management: Parathyroidectomy is advised in patients with significant hypercalcemia, impaired renal function, renal stones, or osteoporosis 2, 3, 4.
- Medical management: For patients with mild asymptomatic disease, contraindications to surgery, or failed previous surgical intervention, medical management may be considered 2, 3, 4.
- Evaluation of fracture risk: Antiresorptive therapy may be used for skeletal protection in patients with an increased fracture risk 4.
Considerations for Vertebral Fractures
- The presence of multiple vertebral compression fractures without trauma history and a very low T score should prompt investigation for underlying diseases such as primary hyperparathyroidism 5.
- Surgical intervention may be necessary for corrective spinal surgery for multiple compression fractures 5.
Treatment Options
- Cinacalcet, a calcimimetic agent, has been shown to effectively lower serum calcium and PTH levels 4.
- Calcium and vitamin D intake should be optimized 4.
- Estrogen therapy may be valuable in postmenopausal women without contraindications to hormone replacement 3.
- Bisphosphonates are potential treatment options and require further study 3.