What is the treatment approach for hyperparathyroidism?

Treatment Approach 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 initially requires medical management with dietary modifications, phosphate binders, and vitamin D supplementation. 1

Primary Hyperparathyroidism (PHPT)

Surgical Management

• Parathyroidectomy is the definitive treatment for PHPT, with two effective surgical approaches: minimally invasive parathyroidectomy (MIP) and bilateral neck exploration (BNE) 1
• MIP is preferred when a single adenoma can be confidently localized preoperatively, offering benefits of shorter operating times, faster recovery, and decreased perioperative costs 1
• BNE remains necessary for cases with discordant/nonlocalizing imaging or suspected multigland disease 2
• Intraoperative PTH monitoring is used to confirm removal of the hyperfunctioning gland during surgery 2

Preoperative Imaging

• Preoperative imaging is essential to localize parathyroid lesions and guide the surgical approach 2
• Multiple imaging modalities may be utilized, including 99Tc-Sestamibi scan, ultrasound, CT scan (4D parathyroid CT), or MRI 2, 1
• Selection of imaging studies should consider surgeon and radiologist preference, regional expertise, and patient-specific characteristics 2

Medical Management

• Medical management may be considered for patients with mild asymptomatic disease, contraindications to surgery, or failed previous surgical intervention 3
• Calcium and vitamin D intake should be optimized to prevent deficiencies 3
• Cinacalcet is indicated for treatment of hypercalcemia in patients with primary HPT who cannot undergo parathyroidectomy 4
• Antiresorptive therapy may be used for skeletal protection in patients with increased fracture risk 3

Secondary Hyperparathyroidism (SHPT)

Medical Management

• Initial treatment includes dietary phosphate restriction, phosphate binders, correction of hypocalcemia, and vitamin D sterols 1
• Aim for 25-OH vitamin D levels >20 ng/ml (50 mmol/l) with native vitamin D supplementation 2
• Ensure adequate calcium intake according to age-related recommended dietary allowance 2
• For elevated PTH levels, increase the dose of active vitamin D and/or decrease the dose of oral phosphate supplements 2
• Cinacalcet is indicated for treatment of SHPT in adult patients with chronic kidney disease on dialysis 4
  • Starting dose is 30 mg once daily, titrated every 2-4 weeks through sequential doses of 30,60,90,120, and 180 mg once daily 4
  • Not indicated for use in patients with CKD who are not on dialysis due to increased risk of hypocalcemia 4

Surgical Management

• Parathyroidectomy is recommended for severe hyperparathyroidism (persistent serum levels of intact PTH >800 pg/mL) associated with hypercalcemia and/or hyperphosphatemia refractory to medical therapy 1
• Surgical options include subtotal parathyroidectomy, total parathyroidectomy with parathyroid tissue autotransplantation, and total parathyroidectomy 1, 5
• Transcervical thymectomy should be performed with parathyroidectomy procedures 5

Tertiary Hyperparathyroidism

• Characterized by lack of PTH suppression despite rising serum calcium levels, often following kidney transplantation in patients with long-standing chronic kidney disease 2
• Surgical excision is recommended for medically refractory cases 2
• As these are typically disorders of multigland disease (parathyroid hyperplasia), imaging should identify all eutopic and potential ectopic or supernumerary glands 2

Postoperative Management

• Monitor ionized calcium every 4-6 hours for the first 48-72 hours after surgery, then twice daily until stable 2
• If ionized calcium falls below normal (<0.9 mmol/L), initiate calcium gluconate infusion at 1-2 mg elemental calcium per kg body weight per hour 2
• When oral intake is possible, administer calcium carbonate 1-2 g three times daily and calcitriol up to 2 μg/day 2
• Adjust phosphate binders based on serum phosphorus levels; some patients may require phosphate supplements 2

Special Considerations

• For persistent or recurrent hyperparathyroidism after initial surgery, imaging with 99Tc-Sestamibi scan, ultrasound, CT scan, or MRI should be performed prior to reoperative surgery 2, 1
• In patients with multiple endocrine neoplasia type 1, persistent hyperparathyroidism is more frequent after subtotal parathyroidectomy than after total parathyroidectomy with autologous graft 5
• For patients with normocalcaemic hyperparathyroidism, active vitamin D might be given without phosphate supplements if careful follow-up is guaranteed 2