From the Guidelines
Primary hyperparathyroidism and secondary hyperparathyroidism both have significant long-term consequences if left untreated, and early intervention is crucial to prevent progressive end-organ damage and maintain quality of life. Primary hyperparathyroidism, typically caused by a parathyroid adenoma, leads to bone demineralization, kidney stones, osteoporosis, and fractures due to excessive calcium mobilization from bones. Patients may develop nephrocalcinosis, chronic kidney disease, cardiovascular complications including hypertension and left ventricular hypertrophy, and neuropsychiatric symptoms such as depression, anxiety, and cognitive impairment. Secondary hyperparathyroidism, which develops due to chronic kidney disease or vitamin D deficiency, causes renal osteodystrophy, vascular calcification, and increased cardiovascular mortality. The mineral bone disorder can lead to bone pain, fractures, and skeletal deformities.
Management of Hyperparathyroidism
Management of primary hyperparathyroidism often involves parathyroidectomy for symptomatic patients, while secondary hyperparathyroidism treatment focuses on addressing the underlying cause with vitamin D supplementation, phosphate binders like sevelamer (800-1600 mg with meals), and calcimimetics such as cinacalcet (starting at 30 mg daily) 1. According to a systematic review and meta-analysis published in the International Journal of Surgery in 2017, total parathyroidectomy (TPTX) is superior to total parathyroidectomy with autotransplantation (TPTX + AT) in reducing the recurrence of secondary hyperparathyroidism, with lower rates of recurrence, recurrence or persistence, and reoperation due to recurrence or persistence 1.
Monitoring and Treatment
Regular monitoring of calcium, phosphorus, PTH levels, and bone density is essential for both conditions to prevent progressive end-organ damage and maintain quality of life. The optimal control of serum phosphorus levels, combined with the use of calcium-based phosphate binders, may result in no further rise of serum PTH levels 1. When serum levels of intact PTH exceed 500 to 600 pg/mL, moderate or even severe hyperparathyroid bone disease is usual, and larger doses of vitamin D sterols are generally required 1.
Key Considerations
- Early intervention is crucial to prevent irreversible complications
- Parathyroidectomy is often necessary for symptomatic primary hyperparathyroidism
- Secondary hyperparathyroidism treatment focuses on addressing the underlying cause
- Regular monitoring of calcium, phosphorus, PTH levels, and bone density is essential
- Total parathyroidectomy (TPTX) may be superior to TPTX + AT in reducing recurrence of secondary hyperparathyroidism 1
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Long-term Consequences of Primary Hyperparathyroidism
- Primary hyperparathyroidism (PHPT) can lead to hypercalcaemia, osteoporosis, renal stones, cardiovascular abnormalities, and reduced quality of life if left untreated 2.
- Surgical removal of abnormal parathyroid tissue (parathyroidectomy) is the only established treatment for adults with symptomatic PHPT to prevent exacerbation of symptoms and to be cured of PHPT 2.
- Parathyroidectomy compared to observation probably results in a large increase in cure rate at six to 24 months follow-up, with an overall cure rate of 99% 2.
Long-term Consequences of Secondary Hyperparathyroidism
- There is limited information available on the long-term consequences of secondary hyperparathyroidism in the provided studies.
- However, it is known that secondary hyperparathyroidism can lead to similar complications as primary hyperparathyroidism, such as osteoporosis, renal stones, and cardiovascular abnormalities.
Bone Mineral Density Changes After Parathyroidectomy
- Bone mineral density improves in up to 75% of patients after curative parathyroidectomy for primary hyperparathyroidism 3.
- Younger patients and those with severe primary hyperparathyroidism may derive the most skeletal benefits from parathyroidectomy 3.
- Parathyroidectomy may have little or no effect on bone mineral density at the lumbar spine and femoral neck after one to two years, but the evidence is very uncertain 2.
Recurrence and Persistence of Hyperparathyroidism
- Recurrence of primary hyperparathyroidism has been reported in 4%-10% of patients after parathyroidectomy 4.
- Risk factors for recurrence include cardiac history, obesity, endoscopic approach, and low-volume center 4.
- Long-term follow-up, even up to 10 years, is necessary to monitor for recurrence and persistence of hyperparathyroidism 4.