Hyperparathyroidism in Emergency Medicine Medication
- Author: Philip N Salen, MD; Chief Editor: Erik D Schraga, MD more...
Medication Summary
Intravenous hydration with isotonic sodium chloride solution adequately reduces calcium levels in most patients with hyperparathyroid-induced hypercalcemia. Restoration of euvolemia with isotonic saline is the mainstay emergency department treatment of hypercalcemia of any cause, including primary hyperparathyroidism.
Bisphosphonate and hormone replacement therapy provide skeletal protection in patients with primary hyperparathyroidism. Neither of these classes of medications significantly lowers serum calcium or PTH levels. The magnitude of the effects of bisphosphonates and estrogen on bone mineral density in primary hyperparathyroidism is comparable to that which occurs after surgical correction of primary hyperparathyroidism.[10] Of the two agents, bisphosphonates are preferred because of the adverse nonskeletal effects of long-term hormone replacement therapy.
The calcimimetic cinacalcet reduces both serum calcium and parathyroid hormone (PTH) levels and raises serum phosphorus. Cinacalcet does not, however, reduce bone turnover or improve BMD. At present, use of this agent in primary hyperparathyroidism is limited to control of serum calcium in patients with symptomatic hypercalcemia who are unable to undergo corrective surgery.[10]
Cinacalcet, a calcimimetic drug that reduces PTH secretion by altering the function of parathyroid calcium-sensing receptors, can be initiated in patients with hypercalcemia secondary to parathyroid carcinoma, secondary hyperparathyroidism, and primary hyperparathyroidism. For hypercalcemia from primary hyperparathyroidism or parathyroid malignancy, the starting dose is usually 30 mg orally twice daily. For those with secondary hyperparathyroidism, the starting dose is 30 mg once daily. After initiation of cinacalcet, measure the serum calcium level within 1 week to allow dose adjustment.
Loop diuretics
Class Summary
These agents may be helpful following hydration in individuals who are hypercalcemic.
Furosemide (Lasix)
Increases excretion of water and calcium. Interferes with chloride-binding cotransport system by inhibiting the reabsorption of sodium and chloride in the ascending loop of Henle and distal renal tubule.
Hormonal therapy
Class Summary
Hormone therapy is indicated in postmenopausal females with hyperparathyroidism.
Estrogen (Premarin)
Reduces bone resorption resulting from hyperparathyroidism.
Calcimimetic agents
Class Summary
Cinacalcet is useful in the management of hyperparathyroid patients for whom parathyroidectomy is contraindicated or in whom surgical correction of their hyperparathyroidism gas failed.[24] Cinacalcet has been shown to significantly lower PTH and calcium levels in patients on dialysis with secondary hyperparathyroid disease ranging from mild to severe.[4] Calcium regulators are also used in hypercalcemia of malignancy. These agents bind to and modulate the parathyroid calcium-sensing receptor, increase sensitivity to extracellular calcium, and reduce PTH secretion. Cinacalcet is a first-in-class calcimimetic drug that works to directly inhibit PTH in patients with CRF.Calcimimetics allosterically modulate the Ca-sensing receptor, increasing its sensitivity to extracellular calcium and thereby lowering PTH secretion from the parathyroid gland.[11]
Cinacalcet is expensive; the cost per month per patient is estimated to vary from about $300 (30 mg) to $1800 (180 mg).
Cinacalcet (Sensipar)
Directly lowers PTH levels by increasing sensitivity of calcium-sensing receptor on chief cell of parathyroid gland to extracellular calcium. Also results in concomitant serum calcium level decrease. Indicated for hypercalcemia with parathyroid carcinoma and for secondary hyperparathyroidism of chronic renal failure.
Bisphosphonate Derivative
Class Summary
Bisphosphonates are effective in decreasing bone turnover in patients with primary hyperparathyroidism and improving bone mineral density. Bisphosphonates have the potential to provide skeletal protection in patients with primary hyperparathyroidism, but the data available confirming this are limited at present. The effect on serum calcium has been inconsistent and may be affected by baseline 25-hyroxyvitamin D levels. Bisphosphonates also do not significantly lower parathyroid hormone levels.[10]
Alendronate
Available in the United States, but not yet indicated for treatment of hypercalcemia; alendronate probably is useful for long-term prevention of recurrence of hypercalcemia following use of more conventional therapy (ie, hydration and pamidronate). Useful in preventing and treating osteoporosis, which is a complication of prolonged mild hypercalcemia.
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