What is the treatment for hyperparathyroidism?

Treatment of Hyperparathyroidism

Surgical parathyroidectomy is the only definitive cure for primary hyperparathyroidism, while secondary hyperparathyroidism requires treatment of the underlying cause along with medical management including phosphate control, vitamin D therapy, and calcimimetics. 1, 2

Primary Hyperparathyroidism

• Surgical excision of abnormal parathyroid tissue is the definitive treatment for primary hyperparathyroidism 1, 2

• Two effective surgical approaches include:

  • Minimally invasive parathyroidectomy (MIP) - offers shorter operating times, faster recovery, and decreased costs 2
  • Bilateral neck exploration (BNE) - necessary for cases with discordant imaging or suspected multigland disease 2

• Indications for surgery include:

  • Symptomatic hyperparathyroidism
  • Age ≤50 years
  • Serum calcium >1 mg/dL above normal
  • Osteoporosis
  • Creatinine clearance <60 mL/min/1.73m²
  • Nephrolithiasis or nephrocalcinosis 3

• For patients unable to undergo surgery, medical options include:

  • Cinacalcet - FDA approved for hypercalcemia in primary hyperparathyroidism when parathyroidectomy is not possible 4
  • Bisphosphonates - can decrease serum calcium and increase bone mineral density 5
  • Raloxifene - may increase bone mineral density and decrease serum calcium in postmenopausal women 5

Secondary Hyperparathyroidism

For CKD-related secondary hyperparathyroidism:

• Initial management includes:

  • Dietary phosphorus restriction and phosphate binders to control serum phosphorus 6, 2
  • Correction of hypocalcemia 2
  • Vitamin D supplementation to achieve 25-OH vitamin D levels >20 ng/mL 1

• For persistent elevated PTH:

  • Vitamin D sterols (calcitriol, paricalcitol, doxercalciferol) with dosage adjusted according to severity of hyperparathyroidism 7, 6
  • For hemodialysis patients, intermittent intravenous administration is more effective than oral administration 6
  • For peritoneal dialysis patients, oral doses of calcitriol (0.5-1.0 μg) or doxercalciferol (2.5-5.0 μg) can be given 2-3 times weekly 7

• Calcimimetics:

  • Cinacalcet - indicated for secondary hyperparathyroidism in CKD patients on dialysis 4
  • Etelcalcetide - indicated for secondary hyperparathyroidism in CKD patients on hemodialysis 8
  • Both effectively decrease serum calcium and PTH levels 4, 8

• Surgical options for severe refractory cases:

  • Consider parathyroidectomy for persistent serum levels of intact PTH >800 pg/mL with hypercalcemia/hyperphosphatemia refractory to medical therapy 2
  • Surgical approaches include subtotal parathyroidectomy, total parathyroidectomy with autotransplantation, or total parathyroidectomy 6, 2

For vitamin D deficiency-related secondary hyperparathyroidism:

• Vitamin D supplementation to correct deficiency 9
• Calcium supplementation as needed 9

Monitoring During Treatment

• For patients on vitamin D sterols:

  • Monitor serum calcium and phosphorus every 2 weeks for 1 month after initiation or dose increase, then monthly 7
  • Monitor PTH monthly for at least 3 months, then every 3 months once target levels achieved 7

• After parathyroidectomy:

  • Monitor ionized calcium every 4-6 hours for first 48-72 hours, then twice daily until stable 6, 1
  • Initiate calcium supplementation as needed 1

Common Pitfalls to Avoid

• Don't delay surgical intervention for primary hyperparathyroidism with symptomatic hypercalcemia or recurrent renal stones 1
• Avoid vitamin D sterols if serum calcium rises above normal range in secondary hyperparathyroidism 6
• Cinacalcet and etelcalcetide are not indicated for CKD patients who are not on dialysis due to increased risk of hypocalcemia 4, 8
• Don't use sodium citrate instead of potassium citrate for patients with hyperparathyroidism and renal stones 1