From the Guidelines
Surgery, specifically parathyroidectomy, is the definitive treatment for primary hyperparathyroidism, and is typically indicated even in asymptomatic patients due to the potential negative effects of long-term hypercalcemia. The treatment approach for hyperparathyroidism depends on the type and severity of the condition. For primary hyperparathyroidism, there are two accepted curative operative strategies: bilateral neck exploration (BNE) and minimally invasive parathyroidectomy (MIP) 1. BNE is 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 only the affected gland, and is often preferred due to its shorter operating times, faster recovery, and decreased perioperative costs 1.
Key Considerations
- The role of imaging in primary hyperparathyroidism is to localize the abnormally functioning gland or glands with high accuracy and high confidence to facilitate targeted curative surgery 1.
- Preoperative imaging is essential in the reoperative setting to localize a target parathyroid lesion (or lesions) and to identify postoperative changes from previous parathyroid explorations that can impact a subsequent surgery 1.
- Persistent hyperparathyroidism is defined as failure to achieve normocalcemia within 6 months of initial parathyroidectomy, whereas recurrent hyperparathyroidism is defined as hypercalcemia occurring after a normocalcemic interval of 6 months or more after parathyroidectomy 1.
Treatment Options
- Parathyroidectomy is the recommended treatment for symptomatic patients, those with significantly elevated calcium levels, reduced kidney function, osteoporosis, or patients under 50 years old.
- For asymptomatic mild cases, monitoring may be appropriate with regular blood calcium checks, bone density scans, and kidney function tests.
- Medical management includes maintaining hydration, moderate calcium intake, and medications like cinacalcet or bisphosphonates for bone protection.
From the FDA Drug Label
1 INDICATIONS AND USAGE
1.1 Secondary Hyperparathyroidism 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)]. 1.2 Parathyroid Carcinoma Cinacalcet tablets are indicated for the treatment of hypercalcemia in adult patients with Parathyroid Carcinoma [see Clinical Studies(14.2)].
- 3 Primary Hyperparathyroidism 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)].
Treatment Options for Hyperparathyroidism:
- Secondary Hyperparathyroidism: Cinacalcet is indicated for the treatment of secondary hyperparathyroidism in adult patients with chronic kidney disease (CKD) on dialysis.
- Parathyroid Carcinoma: Cinacalcet is indicated for the treatment of hypercalcemia in adult patients with parathyroid carcinoma.
- Primary Hyperparathyroidism: Cinacalcet is indicated for the treatment of hypercalcemia in adult patients with primary hyperparathyroidism who are unable to undergo parathyroidectomy. 2
From the Research
Treatment Options for Hyperparathyroidism
- Surgical treatment is considered the most effective treatment for primary hyperparathyroidism, with parathyroidectomy being the standard procedure 3, 4.
- Directed parathyroidectomy is currently the standard technique for treatment of primary hyperparathyroidism worldwide 4.
- Cinacalcet, a positive allosteric modulator of the calcium sensing receptor, is an alternative therapy for patients who cannot or will not undergo surgery, or those with refractory primary hyperparathyroidism after parathyroidectomy 5, 6.
- Cinacalcet has been shown to decrease serum calcium and parathyroid hormone serum levels in patients with primary hyperparathyroidism, but its effects on bone mineral density are uncertain 5, 6.
Surgical Treatment
- Bilateral neck exploration with removal of the affected parathyroid gland and biopsies of other parts is a common surgical approach for primary hyperparathyroidism 3.
- The timing of surgery is crucial, and it is recommended to perform surgery as soon as possible, even if there are no imaging tests, only based on an assessment of the general condition of the patient and their serum calcium levels 3.
- Surgery is the only definitive treatment of primary hyperparathyroidism, and the most appropriate type of surgical procedure depends on the number and localization of the hyperactive parathyroid glands, availability of modern imaging techniques, limitation of each type of procedure, and expertise 4.
Medical Treatment
- Cinacalcet is effective in reducing serum calcium and parathyroid hormone levels in patients with primary hyperparathyroidism, but it can cause adverse gastrointestinal effects, such as nausea and appetite loss 6.
- Other medical treatments, such as estrogens, raloxifene, bisphosphonates, and calcitonin, may also be considered for patients with primary hyperparathyroidism who are not surgical candidates or have refractory disease 5.
- Pharmacological approaches are available and effective for patients with primary hyperparathyroidism who are not candidates for surgery or have contraindications to surgery 7.