What are the treatment options for hyperparathyroidism?

Treatment Options for Hyperparathyroidism

Surgical parathyroidectomy is the definitive treatment for primary hyperparathyroidism, while secondary hyperparathyroidism requires addressing the underlying cause first with medical management and surgery reserved for refractory cases. 1, 2

Types of Hyperparathyroidism and Initial Approach

• Primary hyperparathyroidism (PHPT) is characterized by autonomous overproduction of parathyroid hormone leading to hypercalcemia 3
• Secondary hyperparathyroidism occurs due to alterations in calcium, phosphate, and vitamin D regulation, most commonly in chronic kidney disease (CKD) 4
• Initial evaluation should include measurement of serum calcium, intact parathyroid hormone (iPTH), phosphate, and vitamin D levels 1

Treatment of Primary Hyperparathyroidism

Surgical Management

• Parathyroidectomy is the treatment of choice for symptomatic primary hyperparathyroidism 5

• Indications for surgery include:

  • Significant hypercalcemia (>1 mg/dL above upper limit of normal)
  • Age ≤50 years
  • Osteoporosis
  • Creatinine clearance <60 mL/min/1.73m²
  • Nephrolithiasis or nephrocalcinosis
  • Hypercalciuria (>400 mg/day) 6, 4

• Surgical options include subtotal parathyroidectomy or total parathyroidectomy with or without autotransplantation 7, 1

• Preoperative imaging with 99Tc-sestamibi scan, ultrasound, CT, or MRI helps localize abnormal glands 7, 1

Medical Management for Non-Surgical Candidates

• For patients unable to undergo surgery, medical options include:
  • Cinacalcet: FDA-approved for primary hyperparathyroidism in patients who cannot undergo surgery; effectively reduces serum calcium 8, 5
  • Bisphosphonates (particularly alendronate): Improves bone mineral density without altering serum calcium 5
  • Combination therapy with cinacalcet and bisphosphonates may be used to both reduce calcium and improve bone density 5
• Calcium intake should follow general population guidelines rather than being restricted 5
• Vitamin D repletion to levels ≥50 nmol/L (20 ng/mL) is recommended for patients with low vitamin D 5

Treatment of Secondary Hyperparathyroidism

Medical Management

• Control serum phosphorus through:
  • Dietary phosphorus restriction
  • Phosphate binders (calcium-based or non-calcium based) 2
• Vitamin D therapy:
  • Intermittent intravenous calcitriol or paricalcitol for hemodialysis patients 2
  • Dose adjustment based on severity of hyperparathyroidism 2
• Calcimimetics:
  • Cinacalcet is indicated for secondary hyperparathyroidism in CKD patients on dialysis 8
  • Starting dose is 30 mg once daily, taken with food 8
  • Titrate every 2-4 weeks through sequential doses (30,60,90,120,180 mg daily) to target iPTH levels of 150-300 pg/mL 8
  • Monitor serum calcium and phosphorus within 1 week and iPTH 1-4 weeks after initiation or dose adjustment 8

Surgical Management for Refractory Secondary Hyperparathyroidism

• Parathyroidectomy should be considered for severe hyperparathyroidism with hypercalcemia that precludes medical therapy 2
• Surgical options include:
  • Total parathyroidectomy (TPTX)
  • Total parathyroidectomy with autotransplantation (TPTX+AT)
  • Subtotal parathyroidectomy (SPTX) 2
• Total parathyroidectomy may be superior to autotransplantation regarding recurrent secondary hyperparathyroidism 1, 2
• Total parathyroidectomy is generally not recommended for patients who may subsequently receive kidney transplants due to potential difficulties in calcium management 7

Post-Surgical Management

• Monitor ionized calcium every 4-6 hours for the first 48-72 hours after surgery 1, 2
• If calcium levels fall below normal, initiate calcium gluconate infusion 1
• Administer oral calcium carbonate and calcitriol when oral intake is possible 1
• For secondary hyperparathyroidism patients with CKD on dialysis:
  • If serum calcium falls below 8.4 mg/dL but remains above 7.5 mg/dL, use calcium-containing phosphate binders and/or vitamin D sterols 8
  • If serum calcium falls below 7.5 mg/dL, withhold cinacalcet until serum calcium reaches 8 mg/dL 8

Monitoring Recommendations

• For patients with primary hyperparathyroidism managed conservatively:
  • Biannual measurements of serum calcium
  • Annual measurements of urinary calcium excretion and bone mineral density 6
• For patients on cinacalcet:
  • Monitor serum calcium approximately monthly for secondary hyperparathyroidism
  • Monitor every 2 months for primary hyperparathyroidism 8
• Maintain serum CO2 levels >22 mEq/L in CKD patients to prevent metabolic acidosis that can worsen bone disease 1