Hyperparathyroidism medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Anmol Pitliya, M.B.B.S. M.D.[2]

Surgical therapy is preferred over medical therapy in hyperparathyroidism. However medical therapy is considered in a few circumstances. Patients with primary hyperparathyroidism who do not undergo parathyroidectomy should be monitored for the potential progression of disease. Monitoring includes serum calcium, skeletal monitoring, and renal monitoring. Medical management of primary hyperparathyroidism includes nutritional supplements and pharmacotherapy. Nutritional supplements includes elemental calcium supplements and vitamin D analogs. Pharmacotherapy includes bisphosphonates, calcimimetics, and estrogen receptor-targeted therapy. Medical management of secondary hyperparathyroidism includes calcimimetics, vitamin D analogues, and phosphate binders/phosphate restriction. Medical management of tertiary hyperparathyroidism includes calcimimetics.

Medical therapy for hyperparathyroidism should be considered in the following circumstances:^[1]

• Patients with hyperparathyroidism not meeting the guidelines for surgery.
• Patients with hyperparathyroidism having contraindications to surgery.
• Patient with hyperparathyroidism who have previous unsuccessful neck exploration.
• Patient with hyperparathyroidism who have not been cured by surgery.
• Patient with hyperparathyroidism refuses surgery.

• 1. Primary hyperparathyroidism
  • 1.1 Nutritional supplementation^[2]
    • 1.1.1 Low calcium intake^[3]
      • Preferred regimen (1): Elemental calcium 500 mg PO q24h

      Note: Dietary calcium restriction is not necessary in primary hyperparathyroidism.

    • 1.1.2 Vitamin D depletion
      • Preferred regimen (1): Cholecalciferol 600–1000 IU PO q24h

      Note(1): Vitamin D deficiency is considered when serum level of 25-hydroxy vitamin D is below 50 nM (20 ng/mL).^[4]

      Note(2): Serum calcium levels and urinary calcium excretion should be monitored during vitamin D supplementation. Vitamin D supplementation should be stopped if serum calcium levels is >11.6 mg/dL and/or urinary calcium excretion is >400 mg/24 h.

      Note(3): The goal of vitamin D supplementation is to keep 25-hydroxy vitamin D level between 50 nmol/L to 75 nmol/L.

  • 1.2 Pharmacotherapy
    • 1.2.1 Bisphosphonates
      • Preferred regimen (1): Alendronate 10 mg PO q24h^[5][6]
    • 1.2.2 Calcimimetics
      • Preferred regimen (1): Cinacalcet HCl 30-120 mg PO q12h^[7][8]

      Note(1): Cinacalcet may be used in patients with familial primary hyperparathyroidism as a treatment option for patients having recurrent or persistent hypercalcemia after parathyroidectomy.

      Note(2): A combination of bisphosphonates and calcimimetics may be used to reduce the serum calcium and improve bone mineral density.^[9]

    • 1.2.3 Estrogen receptor-targeted therapy (post-menopausal women)
      • Preferred regimen (1): Conjugated equine estrogen 0.625 mg q24h + medroxyprogesterone acetate 5mg q24h

      Note(1): The risk-benefit ratio should be assessed with respect to known relative or absolute contraindication to use of estrogen in each patient.

• 2. Secondary hyperparathyroidism^[10]
  • 2.1 Secondary hyperparathyroidism due to vitamin D deficiency
    • 2.1.1 Vitamin D analogs
      • Preferred regimen (1): Calcitriol
      • Preferred regimen (2): Paricalcitol
      • Preferred regimen (3): Doxercalciferol
  • 2.2 Secondary hyperparathyroidism due to Chronic renal failure
    • 2.2.1 Vitamin D analogs^[11][12]
      • Preferred regimen (1): Calcitriol 0.5 μg thrice weekly
      • Preferred regimen (2): Paricalcitol 2 μg thrice weekly
      • Preferred regimen (3): Doxercalciferol 1 μg thrice weekly
    • 2.2.2 Phosphate binders/phosphate restriction
    • 2.2.3 Calcimimetics^[13][14]
      • Preferred regimen (1): Cinacalcet HCL 30-180 mg PO q24h
• 3. Tertiary hyperparathyroidism
  • 3.1 Calcimimetic drugs^[15]

    • Preferred regimen (1): Cinacalcet HCL

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