What is the treatment approach for hyperparathyroidism?

Treatment Approach for Hyperparathyroidism

The treatment of hyperparathyroidism should be tailored to the specific type (primary, secondary, or tertiary) with surgical management being the definitive treatment for primary hyperparathyroidism, while secondary hyperparathyroidism requires addressing underlying causes and may be managed medically with vitamin D analogs, calcimimetics, or parathyroidectomy for severe cases. 1, 2

Types of Hyperparathyroidism and Initial Management

Primary Hyperparathyroidism

• Surgical Management:

  • Parathyroidectomy is the only definitive cure 3
  • Indications for surgery:
    • Symptomatic patients
    • Age ≤50 years
    • Serum calcium >1 mg/dL above upper limit of normal
    • Osteoporosis
    • Creatinine clearance <60 mL/min/1.73m²
    • Nephrolithiasis or nephrocalcinosis
    • Hypercalciuria 3
  • Surgical approaches:
    • Bilateral Neck Exploration (BNE)
    • Minimally Invasive Parathyroidectomy (MIP) - offers shorter operating times and faster recovery 1

• Medical Management (when surgery is contraindicated):

  • Bisphosphonates for bone protection
  • Calcimimetics (cinacalcet) for hypercalcemia management 4
  • Regular monitoring of calcium, phosphorus, and PTH levels 1

Secondary Hyperparathyroidism

• In CKD patients:

  1. Address modifiable factors:

     • Treat hyperphosphatemia
     • Correct hypocalcemia
     • Address vitamin D deficiency 2

  2. Medication options:

     • For CKD G3a-G5 not on dialysis: Calcitriol and vitamin D analogs should not be routinely used except in severe and progressive hyperparathyroidism (CKD G4-G5) 2
     • For CKD G5D: Maintain PTH levels approximately 2-9 times the upper normal limit 2
     • Treatment options include:
       • Calcimimetics (cinacalcet)
       • Calcitriol or vitamin D analogs
       • Combination therapy 2, 4

  3. Surgical Management:

     • Parathyroidectomy is recommended for severe hyperparathyroidism that fails to respond to medical therapy 2

• Due to vitamin D deficiency:

  • Vitamin D supplementation
  • Ensure adequate dietary calcium intake 1

Medication Details

Calcimimetics (Cinacalcet)

• Indications:

  • Secondary hyperparathyroidism in CKD patients on dialysis
  • Hypercalcemia in parathyroid carcinoma
  • Primary hyperparathyroidism when surgery is not possible 4

• Dosing:

  • Starting dose: 30 mg once daily
  • Titrate every 2-4 weeks through sequential doses (30,60,90,120,180 mg)
  • Target iPTH: 150-300 pg/mL 4

• Monitoring:

  • Serum calcium within 1 week of initiation or dose adjustment
  • iPTH 1-4 weeks after initiation or dose adjustment 4

Vitamin D and Calcium Management

• Aim for 25-OH vitamin D levels >20 ng/mL (50 nmol/L) 2
• Ensure age-appropriate dietary calcium intake 2
• For elevated PTH with hypercalciuria/hypercalcemia: reduce active vitamin D and phosphate supplements 2

Monitoring Parameters

• For CKD patients:

  • Target PTH levels vary by CKD stage:

    • CKD G3: <70 pg/mL
    • CKD G4: <110 pg/mL
    • CKD G5: <300 pg/mL
    • CKD G5D: 150-600 pg/mL 1

  • Monitoring frequency:

    • CKD G3a-G3b: calcium and phosphate every 6-12 months; PTH once initially
    • CKD G4: calcium and phosphate every 3-6 months; PTH every 6-12 months
    • CKD G5: calcium and phosphate every 1-3 months; PTH every 3-6 months 2

Special Considerations

• For persistent hypercalcemic hyperparathyroidism: Consider parathyroid resection 2
• For normocalcemic hyperparathyroidism: Consider active vitamin D without phosphate supplements or switching to burosumab therapy 2
• For severe hyperparathyroidism despite normocalcemia: Consider calcimimetics with caution due to risk of hypocalcemia 2

Pitfalls and Caveats

• Monitor for hypocalcemia when using calcimimetics, especially in CKD patients
• Cinacalcet is not indicated for CKD patients not on dialysis due to increased risk of hypocalcemia 4
• Surgical management requires experienced surgeons to minimize complications such as hypoparathyroidism and recurrent laryngeal nerve injury 1
• In patients with MEN syndromes, screening for hyperparathyroidism should begin at age 11 or 16 years depending on risk classification 2