What are the treatment options for hyperparathyroidism?

Treatment Options for Hyperparathyroidism

The treatment of hyperparathyroidism depends on the specific type (primary, secondary, or tertiary) with surgical intervention being the definitive treatment for primary hyperparathyroidism, while secondary hyperparathyroidism in CKD requires a stepwise approach starting with phosphorus restriction, vitamin D therapy, and potentially calcimimetics, with parathyroidectomy reserved for severe cases unresponsive to medical management. 1, 2

Types of Hyperparathyroidism and Their Management

Primary Hyperparathyroidism

1. Surgical Management (Parathyroidectomy)

   • Gold standard treatment for primary hyperparathyroidism 2, 3
   • Indications for surgery:
     • Symptomatic patients (all should undergo surgery)
     • 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 2

2. Surgical Approaches

   • Focused, image-guided surgery (minimally invasive parathyroidectomy)
   • Bilateral neck exploration
   • Both achieve high cure rates when performed by experienced surgeons 3
   • Intraoperative PTH monitoring recommended for minimally invasive approach 3

3. Medical Management (for patients who cannot undergo surgery)

   • Antiresorptive therapy (bisphosphonates) for patients with low bone mass
   • Calcimimetics to control serum calcium levels
   • Combined therapy may be considered for patients with hypercalcemia and bone disease 4
   • Hormone replacement therapy may be an option for postmenopausal women 5

Secondary Hyperparathyroidism in Chronic Kidney Disease

1. Dietary Phosphorus Restriction

   • Restrict to 800-1,000 mg/day when serum phosphorus is elevated or PTH levels are above target range 1
   • Monitor serum phosphorus monthly after initiating restriction

2. Vitamin D Therapy

   • Correct vitamin D deficiency with nutritional supplements
   • Use active vitamin D analogs (vitamin D sterols) for more advanced SHPT 1
   • Adjust dosage based on severity of secondary hyperparathyroidism 6

3. Calcimimetics

   • Cinacalcet is indicated for SHPT in adult CKD patients on dialysis 7
   • Starting dose: 30 mg once daily
   • Target iPTH level: 150-300 pg/mL
   • Titrate no more frequently than every 2-4 weeks through sequential doses of 30,60,90,120, and 180 mg once daily 7
   • Not indicated for CKD patients not on dialysis due to increased risk of hypocalcemia 7

4. Combination Therapy

   • Cinacalcet can be used alone or in combination with vitamin D sterols and/or phosphate binders 7
   • Treatment approach based on PTH levels:
     • 150-300 pg/mL: Maintain current therapy
     • 300-500 pg/mL: Increase vitamin D sterols, adjust phosphate binders
     • 500-800 pg/mL: Higher doses of vitamin D sterols, consider adding cinacalcet 1

5. Surgical Intervention (Parathyroidectomy)

   • Consider when PTH levels are >800 pg/mL despite maximal medical therapy
   • Options include total parathyroidectomy with or without autotransplantation, or subtotal parathyroidectomy 1
   • Total parathyroidectomy has lower recurrence rates but higher risk of hypoparathyroidism 1

Monitoring and Follow-up

1. Laboratory Monitoring

   • Serum calcium and phosphorus: Measure within 1 week of treatment initiation or dose adjustment
   • Intact PTH: Measure 1-4 weeks after treatment initiation or dose adjustment 1, 7
   • Once maintenance dose established:
     • Secondary hyperparathyroidism: Monthly calcium monitoring
     • Primary hyperparathyroidism: Every 2 months calcium monitoring 7

2. Management of Hypocalcemia

   • If serum 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 serum calcium falls below 7.5 mg/dL: Withhold cinacalcet until levels reach 8 mg/dL 7
   • Monitor for "hungry bone syndrome" post-parathyroidectomy 1

Special Considerations

1. Vitamin D Deficiency

   • Common in hyperparathyroidism patients
   • Recommend vitamin D supplementation before final decision on surgical treatment for primary hyperparathyroidism 4
   • Correct deficiency in secondary hyperparathyroidism to help control PTH levels 1

2. Quality of Life Benefits

   • Randomized studies have shown improvements in quality of life after parathyroidectomy for primary hyperparathyroidism, though effects have been modest 4, 8
   • One study showed improved function in 2 of 9 domains of the SF-36 health survey after parathyroidectomy compared to observation 8

3. Cost-effectiveness

   • Parathyroidectomy is more cost-effective than observation or pharmacologic therapy for primary hyperparathyroidism 3

Caution: Preoperative parathyroid biopsy should be avoided in primary hyperparathyroidism 3. For patients on cinacalcet, serum calcium must be monitored closely, particularly in CKD patients not on dialysis where it's contraindicated due to hypocalcemia risk 7.