Management of Hyperparathyroidism
Surgical parathyroidectomy is the definitive treatment for primary hyperparathyroidism, while secondary hyperparathyroidism requires targeted medical management based on underlying etiology, with surgery reserved for refractory cases. 1, 2
Primary Hyperparathyroidism Management
Indications for Surgery
- Parathyroidectomy is indicated for symptomatic primary hyperparathyroidism 2
- Surgery should be considered even in asymptomatic patients with any of the following:
Preoperative Localization
- Imaging is essential for localizing parathyroid adenomas before surgery 4
- Recommended imaging modalities include:
Surgical Approaches
- Minimally invasive parathyroidectomy (MIP) is preferred for single adenomas with confident preoperative localization 4
- Bilateral neck exploration is appropriate when multiple gland disease is suspected 1
- Intraoperative PTH monitoring confirms removal of hyperfunctioning tissue 4
Medical Management (when surgery is contraindicated)
- Cinacalcet is indicated for hypercalcemia in primary hyperparathyroidism patients who cannot undergo parathyroidectomy 5
- Starting dose is 30 mg twice daily, titrated every 2-4 weeks as needed to normalize calcium levels 5
- Monitor serum calcium every 2 months once maintenance dose is established 5
Secondary Hyperparathyroidism Management
In Chronic Kidney Disease
Address modifiable factors first: hyperphosphatemia, hypocalcemia, vitamin D deficiency 1
Control serum phosphorus through:
For vitamin D therapy:
- In CKD G3a-G5 not on dialysis: avoid routine use of calcitriol/vitamin D analogs 1
- Reserve for CKD G4-G5 with severe, progressive hyperparathyroidism 1
- For dialysis patients with iPTH >300 pg/mL: administer active vitamin D sterols 1
- Intermittent IV administration is more effective than oral for hemodialysis patients 6
For PTH management in dialysis patients:
- Target iPTH levels approximately 2-9 times upper normal limit 1
- Consider calcimimetics (cinacalcet) for persistent secondary hyperparathyroidism 6
- Starting dose of cinacalcet is 30 mg once daily, titrated every 2-4 weeks 5
- Monitor serum calcium and phosphorus every 2 weeks for 1 month after starting/adjusting dose 1
Surgical Management of Secondary Hyperparathyroidism
- Consider parathyroidectomy for severe hyperparathyroidism (persistent iPTH >800 pg/mL) with hypercalcemia/hyperphosphatemia refractory to medical therapy 1
- Surgical options include:
- TPTX may offer lower recurrence rates compared to TPTX+AT 6
Post-Parathyroidectomy Management
- Monitor ionized calcium every 4-6 hours for first 48-72 hours, then twice daily until stable 1
- If ionized calcium falls below normal (<0.9 mmol/L), initiate calcium gluconate infusion 1
- When oral intake is possible, administer calcium carbonate and calcitriol 1
- Adjust phosphate binders based on serum phosphorus levels 1
Common Pitfalls and Caveats
- Imaging has no utility in confirming or excluding the diagnosis of primary hyperparathyroidism—it is only for localization 4
- Cinacalcet is contraindicated in patients with serum calcium below the lower limit of normal 5
- Cinacalcet is not indicated for CKD patients not on dialysis due to increased hypocalcemia risk 5
- Hypocalcemia is a serious risk after parathyroidectomy; close monitoring and prompt management are essential 2
- Total parathyroidectomy may not be optimal for patients who may receive kidney transplantation in the future 4
- QT interval prolongation and ventricular arrhythmias can occur with hypocalcemia during cinacalcet treatment 5