What are the treatment options for hyperparathyroidism (Primary Hyperparathyroidism)?

From the Guidelines

Surgery, specifically parathyroidectomy, is the definitive treatment for primary hyperparathyroidism, and it is typically recommended even for asymptomatic patients due to the potential negative effects of long-term hypercalcemia. The treatment approach for hyperparathyroidism depends on the severity and type of the condition. For primary hyperparathyroidism, the goal is to remove the overactive parathyroid gland(s) to normalize parathyroid hormone (PTH) levels and alleviate symptoms. According to the most recent guidelines, including the ACR Appropriateness Criteria for parathyroid adenoma 1, surgical excision of the abnormally functioning parathyroid tissue is the preferred treatment, even in asymptomatic cases, due to the potential long-term consequences of hypercalcemia.

There are two accepted curative operative strategies for primary hyperparathyroidism: bilateral neck exploration (BNE) and minimally invasive parathyroidectomy (MIP). BNE involves a bilateral operation where all parathyroid glands are identified and examined, and the diseased glands are resected. MIP, on the other hand, is a unilateral operation that utilizes limited dissection for targeted removal of the affected gland, guided by preoperative localization and intraoperative PTH monitoring 1. The choice between BNE and MIP depends on the presence of a single adenoma, which is the case in approximately 80% of patients, and the accuracy of preoperative localization.

Key considerations in the treatment of hyperparathyroidism include:

• The role of imaging in preoperative localization to facilitate targeted curative surgery
• The importance of intraoperative PTH monitoring to confirm removal of the hyperfunctioning gland
• The challenges and lower cure rates associated with parathyroid reoperations, emphasizing the need for accurate preoperative localization and planning
• The potential benefits of MIP, including shorter operating times, faster recovery, and decreased perioperative costs, for patients with a single adenoma

In cases where surgery is not feasible, medical management may be considered, including the use of cinacalcet to reduce PTH secretion, bisphosphonates to manage bone density loss, and adequate hydration to prevent kidney stones. However, surgical parathyroidectomy remains the most effective treatment for primary hyperparathyroidism, offering a cure for the condition and preventing long-term complications 1.

From the FDA Drug Label

Cinacalcet tablets are indicated for the treatment of secondary hyperparathyroidism (HPT) in adult patients with chronic kidney disease (CKD) on dialysis [see Clinical Studies (14. 1)]. Cinacalcet tablets are indicated for the treatment of hypercalcemia in adult patients with Parathyroid Carcinoma [see Clinical Studies(14.2)]. Cinacalcet tablets are indicated for the treatment of hypercalcemia in adult patients with primary HPT for whom parathyroidectomy would be indicated on the basis of serum calcium levels, but who are unable to undergo parathyroidectomy [see Clinical Studies (14.3)].

The treatment for hyperparathyroidism using cinacalcet tablets is as follows:

• For secondary hyperparathyroidism in patients with chronic kidney disease on dialysis, the recommended starting oral dose is 30 mg once daily.
• For parathyroid carcinoma and primary hyperparathyroidism, the recommended starting oral dose is 30 mg twice daily.
• The dose of cinacalcet tablets should be titrated every 2 to 4 weeks to target iPTH levels of 150 to 300 pg/mL for secondary hyperparathyroidism, and to normalize serum calcium levels for parathyroid carcinoma and primary hyperparathyroidism 2.

From the Research

Treatment Options for Hyperparathyroidism

• Surgical treatment is the only curative option for primary hyperparathyroidism (PHPT) 3, 4, 5, 6
• Parathyroidectomy is recommended for patients with symptoms and those with asymptomatic disease who are at risk of progression or have subclinical evidence of end-organ sequelae 3, 5
• Medical management may be considered for patients with mild asymptomatic disease, contraindications to surgery, or failed previous surgical intervention 3
• Medical interventions available for PHPT patients not undergoing parathyroidectomy include:
  • Optimizing calcium and vitamin D intake
  • Antiresorptive therapy for skeletal protection in patients with increased fracture risk
  • Cinacalcet, a calcimimetic agent, to lower serum calcium and PTH levels 3

Surgical Approaches

• Bilateral neck exploration (BNE) is a consistently valid option with excellent results in the surgical treatment of PHPT and is considered the gold standard 6
• Minimal invasive parathyroidectomy (MIP) is the ideal approach in selected patients with clinically and radiologically considered single-gland disease 6
• Negative imaging is not a contraindication for parathyroid surgery and is not a criterion for the presence or absence of surgical indication 6

Biochemical Profiles

• Patients with PHPT present with a number of distinct biochemical profiles, but as a group, they present with a near-normal Gaussian distribution of both calcium and parathyroid hormone levels 7
• Low 25-hydroxyvitamin D is an expected finding in patients with PHPT, decreasing as serum calcium levels increase 7