How do I manage hyperparathyroidism?

Management of Hyperparathyroidism

For patients with hyperparathyroidism, treatment should be tailored based on the specific type (primary, secondary, or tertiary) with surgical management for primary hyperparathyroidism and medical therapy focusing on correcting underlying abnormalities in secondary hyperparathyroidism.

Types of Hyperparathyroidism and Initial Assessment

• Primary hyperparathyroidism is characterized by elevated calcium levels without appropriate suppression of PTH and is the most common cause of hypercalcemia 1
• Secondary hyperparathyroidism occurs due to alterations in calcium, phosphate, and vitamin D regulation resulting in elevated PTH levels, most commonly in chronic kidney disease (CKD) 1
• Tertiary hyperparathyroidism develops from longstanding secondary hyperparathyroidism with autonomous parathyroid function 2

Management of Primary Hyperparathyroidism

• Surgical excision of abnormal parathyroid tissue is the only definitive cure for primary hyperparathyroidism 3
• Indications for parathyroidectomy include:
  • Presence of symptoms
  • 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 1
• Preoperative localization with ultrasound and/or 99mTc-sestamibi scintigraphy with SPECT/CT is recommended 3
• Surgical options include minimally invasive parathyroidectomy (MIP) or bilateral neck exploration (BNE), with MIP offering shorter operating times and faster recovery 3

Management of Secondary Hyperparathyroidism in CKD

Phosphate Control

• Control serum phosphorus through dietary phosphorus restriction and phosphate binders in patients with CKD-related secondary hyperparathyroidism 4
• Decisions about phosphate-lowering treatment should be based on progressively or persistently elevated serum phosphate 5
• Restrict the dose of calcium-based phosphate binders in adult patients with CKD G3a-G5D 5

Vitamin D Therapy

• For patients with CKD stages G3a-G5 not on dialysis with progressively rising or persistently elevated PTH levels, evaluate for modifiable factors including hyperphosphatemia, hypocalcemia, high phosphate intake, and vitamin D deficiency 5
• In patients with CKD G3a-G5 not on dialysis, calcitriol and vitamin D analogs should not be routinely used 5
• Reserve calcitriol and vitamin D analogs for patients with CKD G4-G5 with severe and progressive hyperparathyroidism 5

For Dialysis Patients

• For hemodialysis or peritoneal dialysis patients with intact PTH levels >300 pg/mL, administer active vitamin D sterol (calcitriol, alfacalcidol, paricalcitol, or doxercalciferol) to reduce PTH to 150-300 pg/mL 5
• Intermittent intravenous administration of calcitriol is more effective than daily oral calcitriol in lowering serum PTH levels 5
• The recommended initial dose of calcitriol is 0.25 mcg/day, which may be increased by 0.25 mcg/day at 4-8 week intervals if satisfactory response is not observed 2
• During titration, monitor serum calcium at least twice weekly and discontinue immediately if hypercalcemia develops 2

PTH Management in Dialysis Patients

• Maintain intact PTH levels in the range of approximately 2-9 times the upper normal limit for the assay in patients with CKD G5D 5
• For patients requiring PTH-lowering therapy, use calcimimetics, calcitriol, vitamin D analogs, or a combination 5
• Monitor serum calcium and phosphorus every 2 weeks for 1 month after initiating vitamin D therapy or increasing the dose, then monthly thereafter 5
• Measure PTH monthly for at least 3 months and then every 3 months once target levels are achieved 5

Surgical Management of Secondary Hyperparathyroidism

• Consider parathyroidectomy for patients with severe hyperparathyroidism (persistent serum levels of intact PTH >800 pg/mL) associated with hypercalcemia and/or hyperphosphatemia refractory to medical therapy 5
• Effective surgical options include subtotal parathyroidectomy or total parathyroidectomy with parathyroid tissue autotransplantation 5
• Total parathyroidectomy may be superior to total parathyroidectomy with autotransplantation in terms of lower recurrence rates 4

Post-Parathyroidectomy Management

• Monitor ionized calcium every 4-6 hours for the first 48-72 hours after surgery, then twice daily until stable 5
• 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 5
• When oral intake is possible, administer calcium carbonate 1-2 g three times daily and calcitriol up to 2 μg/day 5
• Adjust or discontinue phosphate binders based on serum phosphorus levels 5

Management of Secondary Hyperparathyroidism Due to Other Causes

• For secondary hyperparathyroidism due to vitamin D deficiency, supplement with vitamin D to achieve 25-OH vitamin D levels >20 ng/ml 3
• For secondary hyperparathyroidism due to insufficient calcium intake with normal vitamin D levels and kidney function, calcium supplementation (600 mg twice daily) can normalize PTH levels 6

Monitoring and Follow-up

• For patients on treatment, monitor serum calcium, phosphorus, and PTH regularly based on CKD stage and presence of abnormalities 5
• For patients with adynamic bone disease (intact PTH <100 pg/mL), allow plasma levels of PTH to rise by decreasing doses of calcium-based phosphate binders and vitamin D or eliminating such therapy 5