Hyperparathyroidism medical therapy: Difference between revisions
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==Overview== | ==Overview== | ||
Surgical therapy is preferred 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. | 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 [[Kidney|renal]] monitoring. | ||
Medical management of primary hyperparathyroidism includes nutritional supplements and | Medical management of primary hyperparathyroidism includes [[Dietary supplement|nutritional supplements]] and [[pharmacotherapy]]. [[Nutritional supplements]] includes [[elemental calcium]] supplements and [[vitamin D]] analogs. [[Pharmacotherapy]] includes [[Bisphosphonate|bisphosphonates]], calcimimetics, and [[estrogen receptor]]-targeted therapy. | ||
Medical management of secondary hyperparathyroidism includes calcimimetics, vitamin D analogues, and phosphate binders/phosphate | Medical management of secondary hyperparathyroidism includes calcimimetics, [[vitamin D]] analogues, and [[phosphate binders]]/[[phosphate]] restriction. Medical management of tertiary hyperparathyroidism includes calcimimetics. | ||
==Medical Therapy== | ==Medical Therapy== | ||
Medical therapy for hyperparathyroidism should be considered in the following circumstances:<ref name="pmid23374743">{{cite journal| author=Khan AA| title=Medical management of primary hyperparathyroidism. | journal=J Clin Densitom | year= 2013 | volume= 16 | issue= 1 | pages= 60-3 | pmid=23374743 | doi=10.1016/j.jocd.2012.11.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23374743 }} </ref> | Medical therapy for hyperparathyroidism should be considered in the following circumstances:<ref name="pmid23374743">{{cite journal| author=Khan AA| title=Medical management of primary hyperparathyroidism. | journal=J Clin Densitom | year= 2013 | volume= 16 | issue= 1 | pages= 60-3 | pmid=23374743 | doi=10.1016/j.jocd.2012.11.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23374743 }} </ref> | ||
*Patients with | *Patients with hyperparathyroidism not meeting the guidelines for surgery. | ||
*Patients with | *Patients with hyperparathyroidism having contraindications to surgery. | ||
*Patient with | *Patient with hyperparathyroidism who have previous unsuccessful neck exploration. | ||
*Patient with | *Patient with hyperparathyroidism who have not been cured by surgery. | ||
*Patient with | *Patient with hyperparathyroidism refuses surgery. | ||
===Monitoring=== | ===Monitoring=== | ||
Patients with primary hyperparathyroidism who do not undergo parathyroidectomy should be monitored for the potential progression of disease. There are guidelines for monitoring of patients with asymptomatic hyperparathyroidism not undergoing parathyroidectomy. These guidelines include:<ref name="pmid25162665">{{cite journal| author=Bilezikian JP, Brandi ML, Eastell R, Silverberg SJ, Udelsman R, Marcocci C et al.| title=Guidelines for the management of asymptomatic primary hyperparathyroidism: summary statement from the Fourth International Workshop. | journal=J Clin Endocrinol Metab | year= 2014 | volume= 99 | issue= 10 | pages= 3561-9 | pmid=25162665 | doi=10.1210/jc.2014-1413 | pmc=5393490 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25162665 }} </ref> | Patients with primary hyperparathyroidism who do not undergo [[parathyroidectomy]] should be monitored for the potential progression of disease. There are guidelines for monitoring of patients with asymptomatic hyperparathyroidism not undergoing [[parathyroidectomy]]. These guidelines include:<ref name="pmid25162665">{{cite journal| author=Bilezikian JP, Brandi ML, Eastell R, Silverberg SJ, Udelsman R, Marcocci C et al.| title=Guidelines for the management of asymptomatic primary hyperparathyroidism: summary statement from the Fourth International Workshop. | journal=J Clin Endocrinol Metab | year= 2014 | volume= 99 | issue= 10 | pages= 3561-9 | pmid=25162665 | doi=10.1210/jc.2014-1413 | pmc=5393490 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25162665 }} </ref> | ||
*Serum calcium | *'''Serum calcium''' | ||
**Serum calcium should be monitored annually. | **Serum [[calcium]] should be monitored annually. | ||
*Skeletal monitoring | *'''Skeletal monitoring''' | ||
**Dual-energy X-ray absorptiometry (DEXA) is used for skeletal monitoring. DEXA should be done every 1-2 years (at 3 sites). | **[[Dual energy X-ray absorptiometry|Dual-energy X-ray absorptiometry]] ([[Dual energy X-ray absorptiometry|DEXA]]) is used for [[Skeleton|skeletal]] monitoring. [[DEXA scan|DEXA]] should be done every 1-2 years (at 3 sites). | ||
**X-ray or vertebral fracture assessment of spine may be done if indications are present such as height loss, and/or back pain. | **X-ray or vertebral fracture assessment of [[spine]] may be done if indications are present such as height loss, and/or back pain. | ||
*Renal monitoring | *'''Renal monitoring''' | ||
**Estimated glomerular filtration rate (eGFR) and serum creatinine should be done annually. | **Estimated [[glomerular filtration rate]] (eGFR) and [[serum creatinine]] should be done annually. | ||
**24- | **24-hour [[biochemical]] [[Kidney stone|stone]] profile, [[Kidney|renal]] imaging by [[X-rays|x-ray]], [[ultrasound]], or [[CT scan]] may be considered if [[Kidney stone|renal stones]] are suspected. | ||
===Medical Management=== | ===Medical Management=== | ||
| Line 32: | Line 32: | ||
**1.1 Nutritional supplementation<ref name="pmid25162668">{{cite journal| author=Marcocci C, Bollerslev J, Khan AA, Shoback DM| title=Medical management of primary hyperparathyroidism: proceedings of the fourth International Workshop on the Management of Asymptomatic Primary Hyperparathyroidism. | journal=J Clin Endocrinol Metab | year= 2014 | volume= 99 | issue= 10 | pages= 3607-18 | pmid=25162668 | doi=10.1210/jc.2014-1417 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25162668 }} </ref> | **1.1 Nutritional supplementation<ref name="pmid25162668">{{cite journal| author=Marcocci C, Bollerslev J, Khan AA, Shoback DM| title=Medical management of primary hyperparathyroidism: proceedings of the fourth International Workshop on the Management of Asymptomatic Primary Hyperparathyroidism. | journal=J Clin Endocrinol Metab | year= 2014 | volume= 99 | issue= 10 | pages= 3607-18 | pmid=25162668 | doi=10.1210/jc.2014-1417 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25162668 }} </ref> | ||
***1.1.1 Low calcium intake<ref name="pmid12474069">{{cite journal| author=Jorde R, Szumlas K, Haug E, Sundsfjord J| title=The effects of calcium supplementation to patients with primary hyperparathyroidism and a low calcium intake. | journal=Eur J Nutr | year= 2002 | volume= 41 | issue= 6 | pages= 258-63 | pmid=12474069 | doi=10.1007/s00394-002-0383-1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12474069 }} </ref> | ***1.1.1 Low calcium intake<ref name="pmid12474069">{{cite journal| author=Jorde R, Szumlas K, Haug E, Sundsfjord J| title=The effects of calcium supplementation to patients with primary hyperparathyroidism and a low calcium intake. | journal=Eur J Nutr | year= 2002 | volume= 41 | issue= 6 | pages= 258-63 | pmid=12474069 | doi=10.1007/s00394-002-0383-1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12474069 }} </ref> | ||
****Preferred regimen (1): Elemental calcium 500 mg PO q24h | ****Preferred regimen (1): [[Elemental calcium]] 500 mg PO q24h | ||
***: '''Note:''' Dietary calcium restriction is not necessary in primary hyperparathyroidism. | ***: '''Note:''' Dietary [[calcium]] restriction is not necessary in primary hyperparathyroidism. | ||
***1.1.2 Vitamin D depletion | ***1.1.2 [[Vitamin D]] depletion | ||
****Preferred regimen (1): Cholecalciferol 600–1000 IU PO q24h | ****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).<ref name="pmid21118827">{{cite journal| author=Ross AC, Manson JE, Abrams SA, Aloia JF, Brannon PM, Clinton SK et al.| title=The 2011 report on dietary reference intakes for calcium and vitamin D from the Institute of Medicine: what clinicians need to know. | journal=J Clin Endocrinol Metab | year= 2011 | volume= 96 | issue= 1 | pages= 53-8 | pmid=21118827 | doi=10.1210/jc.2010-2704 | pmc=3046611 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21118827 }} </ref> | ***:'''Note(1):''' [[Vitamin D deficiency]] is considered when serum level of 25-hydroxy vitamin D is below 50 nM (20 ng/mL).<ref name="pmid21118827">{{cite journal| author=Ross AC, Manson JE, Abrams SA, Aloia JF, Brannon PM, Clinton SK et al.| title=The 2011 report on dietary reference intakes for calcium and vitamin D from the Institute of Medicine: what clinicians need to know. | journal=J Clin Endocrinol Metab | year= 2011 | volume= 96 | issue= 1 | pages= 53-8 | pmid=21118827 | doi=10.1210/jc.2010-2704 | pmc=3046611 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21118827 }} </ref> | ||
***:'''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(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. | ***:'''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 Pharmacotherapy | ||
***1.2.1 Bisphosphonates | ***1.2.1 [[Bisphosphonate|Bisphosphonates]] | ||
****Preferred regimen (1): Alendronate 10 mg PO q24h<ref name="pmid12574184">{{cite journal| author=Chow CC, Chan WB, Li JK, Chan NN, Chan MH, Ko GT et al.| title=Oral alendronate increases bone mineral density in postmenopausal women with primary hyperparathyroidism. | journal=J Clin Endocrinol Metab | year= 2003 | volume= 88 | issue= 2 | pages= 581-7 | pmid=12574184 | doi=10.1210/jc.2002-020890 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12574184 }} </ref><ref name="pmid15240609">{{cite journal| author=Khan AA, Bilezikian JP, Kung AW, Ahmed MM, Dubois SJ, Ho AY et al.| title=Alendronate in primary hyperparathyroidism: a double-blind, randomized, placebo-controlled trial. | journal=J Clin Endocrinol Metab | year= 2004 | volume= 89 | issue= 7 | pages= 3319-25 | pmid=15240609 | doi=10.1210/jc.2003-030908 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15240609 }} </ref> | ****Preferred regimen (1): [[Alendronate]] 10 mg PO q24h<ref name="pmid12574184">{{cite journal| author=Chow CC, Chan WB, Li JK, Chan NN, Chan MH, Ko GT et al.| title=Oral alendronate increases bone mineral density in postmenopausal women with primary hyperparathyroidism. | journal=J Clin Endocrinol Metab | year= 2003 | volume= 88 | issue= 2 | pages= 581-7 | pmid=12574184 | doi=10.1210/jc.2002-020890 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12574184 }} </ref><ref name="pmid15240609">{{cite journal| author=Khan AA, Bilezikian JP, Kung AW, Ahmed MM, Dubois SJ, Ho AY et al.| title=Alendronate in primary hyperparathyroidism: a double-blind, randomized, placebo-controlled trial. | journal=J Clin Endocrinol Metab | year= 2004 | volume= 89 | issue= 7 | pages= 3319-25 | pmid=15240609 | doi=10.1210/jc.2003-030908 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15240609 }} </ref> | ||
***1.2.2 Calcimimetics | ***1.2.2 Calcimimetics | ||
****Preferred regimen (1): Cinacalcet HCl 30-120 mg PO q12h<ref name="pmid15522938">{{cite journal| author=Peacock M, Bilezikian JP, Klassen PS, Guo MD, Turner SA, Shoback D| title=Cinacalcet hydrochloride maintains long-term normocalcemia in patients with primary hyperparathyroidism. | journal=J Clin Endocrinol Metab | year= 2005 | volume= 90 | issue= 1 | pages= 135-41 | pmid=15522938 | doi=10.1210/jc.2004-0842 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15522938 }} </ref><ref name="pmid23730501">{{cite journal| author=Luque-Fernández I, García-Martín A, Luque-Pazos A| title=Experience with cinacalcet in primary hyperparathyroidism: results after 1 year of treatment. | journal=Ther Adv Endocrinol Metab | year= 2013 | volume= 4 | issue= 3 | pages= 77-81 | pmid=23730501 | doi=10.1177/2042018813482344 | pmc=3666442 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23730501 }} </ref> | ****Preferred regimen (1): [[Cinacalcet]] HCl 30-120 mg PO q12h<ref name="pmid15522938">{{cite journal| author=Peacock M, Bilezikian JP, Klassen PS, Guo MD, Turner SA, Shoback D| title=Cinacalcet hydrochloride maintains long-term normocalcemia in patients with primary hyperparathyroidism. | journal=J Clin Endocrinol Metab | year= 2005 | volume= 90 | issue= 1 | pages= 135-41 | pmid=15522938 | doi=10.1210/jc.2004-0842 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15522938 }} </ref><ref name="pmid23730501">{{cite journal| author=Luque-Fernández I, García-Martín A, Luque-Pazos A| title=Experience with cinacalcet in primary hyperparathyroidism: results after 1 year of treatment. | journal=Ther Adv Endocrinol Metab | year= 2013 | volume= 4 | issue= 3 | pages= 77-81 | pmid=23730501 | doi=10.1177/2042018813482344 | pmc=3666442 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23730501 }} </ref> | ||
***:'''Note(1):''' | ***:'''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 | ***:'''Note(2):''' A combination of [[Bisphosphonate|bisphosphonates]] and calcimimetics may be used to reduce the serum [[calcium]] and improve [[bone mineral density]].<ref name="pmid21445714">{{cite journal| author=Faggiano A, Di Somma C, Ramundo V, Severino R, Vuolo L, Coppola A et al.| title=Cinacalcet hydrochloride in combination with alendronate normalizes hypercalcemia and improves bone mineral density in patients with primary hyperparathyroidism. | journal=Endocrine | year= 2011 | volume= 39 | issue= 3 | pages= 283-7 | pmid=21445714 | doi=10.1007/s12020-011-9459-0 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21445714 }} </ref> | ||
***1.2.3 Estrogen | ***1.2.3 Estrogen receptor-targeted therapy ([[Postmenopausal|post-menopausal women]]) | ||
****Preferred regimen (1): Conjugated equine estrogen 0.625 mg q24h + medroxyprogesterone acetate 5mg q24h | ****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. | ***:'''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<ref name="pmid18957950">{{cite journal| author=Wetmore JB, Quarles LD| title=Calcimimetics or vitamin D analogs for suppressing parathyroid hormone in end-stage renal disease: time for a paradigm shift? | journal=Nat Clin Pract Nephrol | year= 2009 | volume= 5 | issue= 1 | pages= 24-33 | pmid=18957950 | doi=10.1038/ncpneph0977 | pmc=3924719 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18957950 }} </ref> | *2. Secondary hyperparathyroidism<ref name="pmid18957950">{{cite journal| author=Wetmore JB, Quarles LD| title=Calcimimetics or vitamin D analogs for suppressing parathyroid hormone in end-stage renal disease: time for a paradigm shift? | journal=Nat Clin Pract Nephrol | year= 2009 | volume= 5 | issue= 1 | pages= 24-33 | pmid=18957950 | doi=10.1038/ncpneph0977 | pmc=3924719 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18957950 }} </ref> | ||
**2.1 Secondary hyperparathyroidism due to vitamin D deficiency | **2.1 Secondary hyperparathyroidism due to [[vitamin D deficiency]] | ||
***2.1.1 Vitamin D analogs | ***2.1.1 Vitamin D analogs | ||
****Preferred regimen (1): Calcitriol | ****Preferred regimen (1): [[Calcitriol]] | ||
****Preferred regimen (2): Paricalcitol | ****Preferred regimen (2): [[Paricalcitol]] | ||
****Preferred regimen (3): Doxercalciferol | ****Preferred regimen (3): [[Doxercalciferol]] | ||
**2.2 Secondary hyperparathyroidism due to Chronic renal failure | **2.2 Secondary hyperparathyroidism due to Chronic renal failure | ||
***2.2.1 Calcimimetics<ref name="pmid16632010">{{cite journal| author=Strippoli GF, Palmer S, Tong A, Elder G, Messa P, Craig JC| title=Meta-analysis of biochemical and patient-level effects of calcimimetic therapy. | journal=Am J Kidney Dis | year= 2006 | volume= 47 | issue= 5 | pages= 715-26 | pmid=16632010 | doi=10.1053/j.ajkd.2006.01.015 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16632010 }} </ref><ref name="pmid15673327">{{cite journal| author=Moe SM, Chertow GM, Coburn JW, Quarles LD, Goodman WG, Block GA et al.| title=Achieving NKF-K/DOQI bone metabolism and disease treatment goals with cinacalcet HCl. | journal=Kidney Int | year= 2005 | volume= 67 | issue= 2 | pages= 760-71 | pmid=15673327 | doi=10.1111/j.1523-1755.2005.67139.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15673327 }} </ref> | ***2.2.1 Calcimimetics<ref name="pmid16632010">{{cite journal| author=Strippoli GF, Palmer S, Tong A, Elder G, Messa P, Craig JC| title=Meta-analysis of biochemical and patient-level effects of calcimimetic therapy. | journal=Am J Kidney Dis | year= 2006 | volume= 47 | issue= 5 | pages= 715-26 | pmid=16632010 | doi=10.1053/j.ajkd.2006.01.015 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16632010 }} </ref><ref name="pmid15673327">{{cite journal| author=Moe SM, Chertow GM, Coburn JW, Quarles LD, Goodman WG, Block GA et al.| title=Achieving NKF-K/DOQI bone metabolism and disease treatment goals with cinacalcet HCl. | journal=Kidney Int | year= 2005 | volume= 67 | issue= 2 | pages= 760-71 | pmid=15673327 | doi=10.1111/j.1523-1755.2005.67139.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15673327 }} </ref> | ||
****Preferred regimen (1): Cinacalcet HCL 30-180 mg PO q24h | ****Preferred regimen (1): [[Cinacalcet]] HCL 30-180 mg PO q24h | ||
***2.2.2 Phosphate binders/phosphate restriction | ***2.2.2 Phosphate binders/phosphate restriction | ||
***2.2.3 Vitamin D analogs<ref name="pmid18310602">{{cite journal| author=Block GA, Zeig S, Sugihara J, Chertow GM, Chi EM, Turner SA et al.| title=Combined therapy with cinacalcet and low doses of vitamin D sterols in patients with moderate to severe secondary hyperparathyroidism. | journal=Nephrol Dial Transplant | year= 2008 | volume= 23 | issue= 7 | pages= 2311-8 | pmid=18310602 | doi=10.1093/ndt/gfn026 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18310602 }} </ref><ref name="pmid17699221">{{cite journal| author=Chertow GM, Blumenthal S, Turner S, Roppolo M, Stern L, Chi EM et al.| title=Cinacalcet hydrochloride (Sensipar) in hemodialysis patients on active vitamin D derivatives with controlled PTH and elevated calcium x phosphate. | journal=Clin J Am Soc Nephrol | year= 2006 | volume= 1 | issue= 2 | pages= 305-12 | pmid=17699221 | doi=10.2215/CJN.00870805 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17699221 }} </ref> | ***2.2.3 Vitamin D analogs<ref name="pmid18310602">{{cite journal| author=Block GA, Zeig S, Sugihara J, Chertow GM, Chi EM, Turner SA et al.| title=Combined therapy with cinacalcet and low doses of vitamin D sterols in patients with moderate to severe secondary hyperparathyroidism. | journal=Nephrol Dial Transplant | year= 2008 | volume= 23 | issue= 7 | pages= 2311-8 | pmid=18310602 | doi=10.1093/ndt/gfn026 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18310602 }} </ref><ref name="pmid17699221">{{cite journal| author=Chertow GM, Blumenthal S, Turner S, Roppolo M, Stern L, Chi EM et al.| title=Cinacalcet hydrochloride (Sensipar) in hemodialysis patients on active vitamin D derivatives with controlled PTH and elevated calcium x phosphate. | journal=Clin J Am Soc Nephrol | year= 2006 | volume= 1 | issue= 2 | pages= 305-12 | pmid=17699221 | doi=10.2215/CJN.00870805 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17699221 }} </ref> | ||
****Preferred regimen (1): Calcitriol 0.5 μg thrice weekly | ****Preferred regimen (1): [[Calcitriol]] 0.5 μg thrice weekly | ||
****Preferred regimen (2): Paricalcitol 2 μg thrice weekly | ****Preferred regimen (2): [[Paricalcitol]] 2 μg thrice weekly | ||
****Preferred regimen (3): Doxercalciferol 1 μg thrice weekly | ****Preferred regimen (3): [[Doxercalciferol]] 1 μg thrice weekly | ||
*3. Secondary hyperparathyroidism | *3. Secondary hyperparathyroidism | ||
**3.1 Calcimimetic drugs<ref name="pmid28518414">{{cite journal| author=Dulfer RR, Franssen GJH, Hesselink DA, Hoorn EJ, van Eijck CHJ, van Ginhoven TM| title=Systematic review of surgical and medical treatment for tertiary hyperparathyroidism. | journal=Br J Surg | year= 2017 | volume= 104 | issue= 7 | pages= 804-813 | pmid=28518414 | doi=10.1002/bjs.10554 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28518414 }} </ref> | **3.1 Calcimimetic drugs<ref name="pmid28518414">{{cite journal| author=Dulfer RR, Franssen GJH, Hesselink DA, Hoorn EJ, van Eijck CHJ, van Ginhoven TM| title=Systematic review of surgical and medical treatment for tertiary hyperparathyroidism. | journal=Br J Surg | year= 2017 | volume= 104 | issue= 7 | pages= 804-813 | pmid=28518414 | doi=10.1002/bjs.10554 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28518414 }} </ref> | ||
**:*Preferred regimen (1): Cinacalcet HCL | **:*Preferred regimen (1): [[Cinacalcet]] HCL | ||
==References== | ==References== | ||
Revision as of 19:53, 29 August 2017
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Hyperparathyroidism Microchapters |
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Hyperparathyroidism medical therapy On the Web |
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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]
Overview
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
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.
Monitoring
Patients with primary hyperparathyroidism who do not undergo parathyroidectomy should be monitored for the potential progression of disease. There are guidelines for monitoring of patients with asymptomatic hyperparathyroidism not undergoing parathyroidectomy. These guidelines include:[2]
- Serum calcium
- Serum calcium should be monitored annually.
- Skeletal monitoring
- Dual-energy X-ray absorptiometry (DEXA) is used for skeletal monitoring. DEXA should be done every 1-2 years (at 3 sites).
- X-ray or vertebral fracture assessment of spine may be done if indications are present such as height loss, and/or back pain.
- Renal monitoring
- Estimated glomerular filtration rate (eGFR) and serum creatinine should be done annually.
- 24-hour biochemical stone profile, renal imaging by x-ray, ultrasound, or CT scan may be considered if renal stones are suspected.
Medical Management
- 1. Primary hyperparathyroidism
- 1.1 Nutritional supplementation[3]
- 1.1.1 Low calcium intake[4]
- 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).[5]
- 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.
- 1.1.1 Low calcium intake[4]
- 1.2 Pharmacotherapy
- 1.2.1 Bisphosphonates
- Preferred regimen (1): Alendronate 10 mg PO q24h[6][7]
- 1.2.2 Calcimimetics
- Preferred regimen (1): Cinacalcet HCl 30-120 mg PO q12h[8][9]
- 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.[10]
- 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.
- 1.2.1 Bisphosphonates
- 1.1 Nutritional supplementation[3]
- 2. Secondary hyperparathyroidism[11]
- 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
- 2.1.1 Vitamin D analogs
- 2.2 Secondary hyperparathyroidism due to Chronic renal failure
- 2.2.1 Calcimimetics[12][13]
- Preferred regimen (1): Cinacalcet HCL 30-180 mg PO q24h
- 2.2.2 Phosphate binders/phosphate restriction
- 2.2.3 Vitamin D analogs[14][15]
- 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
- 2.2.1 Calcimimetics[12][13]
- 2.1 Secondary hyperparathyroidism due to vitamin D deficiency
- 3. Secondary hyperparathyroidism
- 3.1 Calcimimetic drugs[16]
- Preferred regimen (1): Cinacalcet HCL
- 3.1 Calcimimetic drugs[16]
References
- ↑ Khan AA (2013). "Medical management of primary hyperparathyroidism". J Clin Densitom. 16 (1): 60–3. doi:10.1016/j.jocd.2012.11.010. PMID 23374743.
- ↑ Bilezikian JP, Brandi ML, Eastell R, Silverberg SJ, Udelsman R, Marcocci C; et al. (2014). "Guidelines for the management of asymptomatic primary hyperparathyroidism: summary statement from the Fourth International Workshop". J Clin Endocrinol Metab. 99 (10): 3561–9. doi:10.1210/jc.2014-1413. PMC 5393490. PMID 25162665.
- ↑ Marcocci C, Bollerslev J, Khan AA, Shoback DM (2014). "Medical management of primary hyperparathyroidism: proceedings of the fourth International Workshop on the Management of Asymptomatic Primary Hyperparathyroidism". J Clin Endocrinol Metab. 99 (10): 3607–18. doi:10.1210/jc.2014-1417. PMID 25162668.
- ↑ Jorde R, Szumlas K, Haug E, Sundsfjord J (2002). "The effects of calcium supplementation to patients with primary hyperparathyroidism and a low calcium intake". Eur J Nutr. 41 (6): 258–63. doi:10.1007/s00394-002-0383-1. PMID 12474069.
- ↑ Ross AC, Manson JE, Abrams SA, Aloia JF, Brannon PM, Clinton SK; et al. (2011). "The 2011 report on dietary reference intakes for calcium and vitamin D from the Institute of Medicine: what clinicians need to know". J Clin Endocrinol Metab. 96 (1): 53–8. doi:10.1210/jc.2010-2704. PMC 3046611. PMID 21118827.
- ↑ Chow CC, Chan WB, Li JK, Chan NN, Chan MH, Ko GT; et al. (2003). "Oral alendronate increases bone mineral density in postmenopausal women with primary hyperparathyroidism". J Clin Endocrinol Metab. 88 (2): 581–7. doi:10.1210/jc.2002-020890. PMID 12574184.
- ↑ Khan AA, Bilezikian JP, Kung AW, Ahmed MM, Dubois SJ, Ho AY; et al. (2004). "Alendronate in primary hyperparathyroidism: a double-blind, randomized, placebo-controlled trial". J Clin Endocrinol Metab. 89 (7): 3319–25. doi:10.1210/jc.2003-030908. PMID 15240609.
- ↑ Peacock M, Bilezikian JP, Klassen PS, Guo MD, Turner SA, Shoback D (2005). "Cinacalcet hydrochloride maintains long-term normocalcemia in patients with primary hyperparathyroidism". J Clin Endocrinol Metab. 90 (1): 135–41. doi:10.1210/jc.2004-0842. PMID 15522938.
- ↑ Luque-Fernández I, García-Martín A, Luque-Pazos A (2013). "Experience with cinacalcet in primary hyperparathyroidism: results after 1 year of treatment". Ther Adv Endocrinol Metab. 4 (3): 77–81. doi:10.1177/2042018813482344. PMC 3666442. PMID 23730501.
- ↑ Faggiano A, Di Somma C, Ramundo V, Severino R, Vuolo L, Coppola A; et al. (2011). "Cinacalcet hydrochloride in combination with alendronate normalizes hypercalcemia and improves bone mineral density in patients with primary hyperparathyroidism". Endocrine. 39 (3): 283–7. doi:10.1007/s12020-011-9459-0. PMID 21445714.
- ↑ Wetmore JB, Quarles LD (2009). "Calcimimetics or vitamin D analogs for suppressing parathyroid hormone in end-stage renal disease: time for a paradigm shift?". Nat Clin Pract Nephrol. 5 (1): 24–33. doi:10.1038/ncpneph0977. PMC 3924719. PMID 18957950.
- ↑ Strippoli GF, Palmer S, Tong A, Elder G, Messa P, Craig JC (2006). "Meta-analysis of biochemical and patient-level effects of calcimimetic therapy". Am J Kidney Dis. 47 (5): 715–26. doi:10.1053/j.ajkd.2006.01.015. PMID 16632010.
- ↑ Moe SM, Chertow GM, Coburn JW, Quarles LD, Goodman WG, Block GA; et al. (2005). "Achieving NKF-K/DOQI bone metabolism and disease treatment goals with cinacalcet HCl". Kidney Int. 67 (2): 760–71. doi:10.1111/j.1523-1755.2005.67139.x. PMID 15673327.
- ↑ Block GA, Zeig S, Sugihara J, Chertow GM, Chi EM, Turner SA; et al. (2008). "Combined therapy with cinacalcet and low doses of vitamin D sterols in patients with moderate to severe secondary hyperparathyroidism". Nephrol Dial Transplant. 23 (7): 2311–8. doi:10.1093/ndt/gfn026. PMID 18310602.
- ↑ Chertow GM, Blumenthal S, Turner S, Roppolo M, Stern L, Chi EM; et al. (2006). "Cinacalcet hydrochloride (Sensipar) in hemodialysis patients on active vitamin D derivatives with controlled PTH and elevated calcium x phosphate". Clin J Am Soc Nephrol. 1 (2): 305–12. doi:10.2215/CJN.00870805. PMID 17699221.
- ↑ Dulfer RR, Franssen GJH, Hesselink DA, Hoorn EJ, van Eijck CHJ, van Ginhoven TM (2017). "Systematic review of surgical and medical treatment for tertiary hyperparathyroidism". Br J Surg. 104 (7): 804–813. doi:10.1002/bjs.10554. PMID 28518414.