PTH-lowering Drugs and Parathyroidectomy: Whats New?
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Dr Jacob George, Thiruvananthapuram 09 January 2018
Early cases of hyperphosphatemia may respond to dietary phosphate restriction but may need phosphate binding drugs if ineffective. Calcium-based phosphate binders are preferred if serum calcium levels are low or normal, especially when vitamin D or its derivatives are not used concomitantly. There is a risk of vascular calcification especially when the calcium-phosphorus product is >55 and in patients undergoing dialysis.
Noncalcium-based phosphate binders are preferred when the calcium levels are elevated and when vitamin D derivatives are being used to decrease the risk of vascular calcification. Nutritional vitamin D deficiency can be corrected by use of ergocalciferol (Vit D2) or cholecalciferol (Vit D3) with monitoring of serum calcium levels.
If PTH levels fail to respond, active vitamin D (calcitriol) or synthetic vitamin D derivatives can be used. However, if elevated PTH levels are associated with serum calcium >8.4 mg/dL, risk of vascular calcification may be enhanced with these drugs. Drugs that directly act on the calcium sensing receptor of the parathyroid gland may be useful in such cases. Patients with long-standing elevated PTH levels may have developed hyperplasia of the parathyroid glands and may be refractory to the above measures. Various types of parathyroidectomy (subtotal/total) with or without autotransplantation may then be considered. Patients who develop calciphylaxis with skin ischemia and necrosis may also benefit from parathyroidectomy. A marked improvement in pruritus, bone abnormalities and several other uremic symptoms has been observed following parathyroidectomy.
Management of CKD thus appears to be incomplete without tackling elevated PTH levels.
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