Management of Elevated Parathyroid Hormone Levels

Initial Diagnostic Approach

• The American College of Physicians recommends measuring serum calcium, phosphorus, and 25-hydroxyvitamin D levels immediately to differentiate between primary and secondary hyperparathyroidism and guide management 1, 2
• If serum calcium is elevated, this suggests primary hyperparathyroidism; surgical consultation for parathyroidectomy should be considered if the patient meets criteria 1
• Assessing kidney function (eGFR) is necessary to determine if chronic kidney disease (CKD) is contributing to elevated parathyroid hormone (PTH) levels 2

Management Based on Clinical Context

For Patients WITHOUT CKD

• The National Kidney Foundation recommends correcting vitamin D deficiency if 25-hydroxyvitamin D is <30 ng/mL using ergocalciferol or cholecalciferol 2
• Target 25-hydroxyvitamin D levels >30 ng/mL, though recent evidence suggests levels >125 nmol/l may be needed for optimal PTH suppression 3
• Providing calcium supplementation if dietary intake is inadequate is recommended, using calcium citrate in malabsorption syndromes 2

For Patients WITH CKD Not on Dialysis

• The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend controlling serum phosphorus first through dietary phosphorus restriction and phosphate binders if needed, targeting normal range 1
• Correcting vitamin D deficiency with ergocalciferol or cholecalciferol if 25-hydroxyvitamin D <30 ng/mL is recommended 2
• Initiating active vitamin D therapy (calcitriol, paricalcitol, or doxercalciferol) to suppress PTH is recommended 1

For Patients WITH CKD on Dialysis

• The Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines recommend targeting PTH levels of 150-300 pg/mL for dialysis patients 4, 5
• Reducing or holding active vitamin D therapy if the patient is currently receiving it is recommended if PTH levels are already controlled 6, 4
• Reducing phosphate binder doses if appropriate is recommended, as excessive phosphate control combined with vitamin D can over-suppress PTH 6

Special Populations

X-Linked Hypophosphatemia (XLH)

• Optimizing active vitamin D dose (increase) and reducing phosphate dose first is recommended if PTH elevation occurs in XLH patients on conventional therapy 6
• Considering cinacalcet with close monitoring is recommended if PTH does not normalize after optimization, though it is not licensed for this indication and carries risk of hypocalcemia and QT prolongation 6
• Parathyroidectomy should be considered for tertiary hypercalcemic hyperparathyroidism 6, 1