From the Guidelines
Surgery is the definitive treatment for primary hyperparathyroidism, and minimally invasive parathyroidectomy (MIP) is often the preferred approach for patients with a single parathyroid adenoma, as it conveys the benefits of shorter operating times, faster recovery, and decreased perioperative costs 1.
Treatment Overview
Hyperparathyroidism is a condition characterized by excessive parathyroid hormone (PTH) production, leading to hypercalcemia. The most common form, primary hyperparathyroidism (PHPT), is typically caused by a single parathyroid adenoma (80%) and can also occur due to multiple adenomas, parathyroid hyperplasia, or parathyroid carcinoma 1.
Diagnostic Considerations
Diagnosis of PHPT is made by biochemical testing, specifically serum calcium and serum PTH levels. Imaging has no utility in confirming or excluding the diagnosis of PHPT but plays a crucial role in localizing the abnormally functioning gland or glands to facilitate targeted curative surgery 1.
Surgical Approaches
There are two accepted curative operative strategies for PHPT: bilateral neck exploration (BNE) and minimally invasive parathyroidectomy (MIP). BNE is a bilateral operation where all parathyroid glands are identified and examined, while MIP is a unilateral operation utilizing limited dissection for targeted removal of only the affected gland 1.
- BNE is traditionally the standard surgical method and is necessary in cases of discordant or nonlocalizing preoperative imaging or when there is high suspicion for multigland disease (MGD) 1.
- MIP is often performed for patients with a single adenoma, as it offers shorter operating times, faster recovery, and decreased perioperative costs 1.
Postoperative Considerations
Persistent PHPT is defined as failure to achieve normocalcemia within 6 months of initial parathyroidectomy, whereas recurrent PHPT is defined as hypercalcemia occurring after a normocalcemic interval of 6 months or more after parathyroidectomy 1. Parathyroid reoperations are surgically challenging, with lower cure rates than first-time surgery and higher complication rates, emphasizing the importance of precise preoperative localization and intraoperative PTH monitoring 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)].
Hyperparathyroidism Treatment: Cinacalcet tablets are indicated for the treatment of:
- Secondary Hyperparathyroidism in adult patients with chronic kidney disease (CKD) on dialysis
- Parathyroid Carcinoma in adult patients with hypercalcemia
- Primary Hyperparathyroidism in adult patients with hypercalcemia who are unable to undergo parathyroidectomy 2
From the Research
Definition and Symptoms of Hyperparathyroidism
- Hyperparathyroidism is a condition where the parathyroid glands produce excess parathyroid hormone (PTH), leading to hypercalcemia 3.
- Primary hyperparathyroidism (PHPT) is the most common cause of hypercalcemia in the outpatient setting 3.
- Symptoms of PHPT include non-specific signs and symptoms of hypercalcemia, skeletal fragility, nephrolithiasis, and nephrocalcinosis 3.
Diagnosis and Treatment of Hyperparathyroidism
- Diagnosis of PHPT is often made through routine biochemical screening, and the majority of individuals present at an asymptomatic stage 3.
- Indications for surgery have recently been revised, and parathyroidectomy is advised in patients younger than 50 years old and in the presence of significant hypercalcemia, impaired renal function, renal stones, or osteoporosis 3.
- Medical management may be considered in those with mild asymptomatic disease, contraindications to surgery, or failed previous surgical intervention 3.
- Cinacalcet, a calcimimetic agent, has been shown to effectively lower serum calcium and PTH levels [(3,4)].
Medical Management of Hyperparathyroidism
- Medical treatment options for PHPT include calcium and vitamin D intake optimization, antiresorptive therapy for skeletal protection, and cinacalcet [(3,5)].
- Cinacalcet has been shown to control hypercalcemia and hypophosphatemia, lower PTH levels, and improve cognitive parameters 4.
- Bisphosphonates, such as pamidronate, alendronate, and clodronate, have been shown to improve bone mineral density (BMD) 5.
- Combining resorptive agents with calcimimetics may be a rewarding approach, but more studies are warranted 5.
Secondary Hyperparathyroidism
- Secondary hyperparathyroidism (SHPT) develops as a result of impaired calcium homeostasis in patients with chronic kidney disease 6.
- Cinacalcet HCl has been shown to be effective in treating SHPT, reducing PTH levels, and lowering calcium, phosphorus, and calcium-phosphorus product 6.
- Cinacalcet HCl has been associated with a beneficial effect on relative risks of parathyroidectomy, fracture, and hospitalization for cardiovascular complications 6.