Background: Primary hyperparathyroidism is one of the most common disorders encountered in endocrine clinics and primarily affects women. The current recommendation for patients with primary hyperparathyroidism is to undergo parathyroidectomy which has a 97% success rate. However, there is a small group of patients where surgery is contraindicated, or patients who have a disease pattern not amenable to surgery or patients who refuse surgery. These patients would require an alternative treatment to manage hypercalcemia. Cinacalcet is an allosteric modulator of calcium sensing receptor and is currently commissioned by NHS England for patients with primary hyperparathyroidism who are not suitable for surgery and patients with secondary hyperparathyroidism with end stage kidney disease on dialysis. It is also indicated in treating hypercalcemia secondary to parathyroid carcinoma. European Medicines Agency and British National Formulary both endorse the use of Cinacalcet in these patients.
Method: We conducted a retrospective audit on the patients with primary hyperparathyroidism who were prescribed Cinacalcet against the NHS England Clinical Commissioning Policy (July 2016).
Results: A total of 17 patients were identified as suitable to be included in the audit. Majority of the patients are female (n=16/17) and only one male. The age range is between 54 to 91 years old (mean=78). Pre treatment calcium levels are between 2.593.3 mmol/L (mean=2.85 mmol/L) and PTH level between 8.9257.65 pmol/L (mean=19.06). Vitamin D levels are between 9.9999.26 nmol/L prior to treatment. Seven patients had low vitamin D levels (<50 nmol/L) and one patient did not have vitamin D levels prior to treatment. Calcium levels diminish after 1 month of treatment and were between 2.263.09 mmol/L (mean=2.5 mmol/L). Nine patients were started on Cinacalcet as a primary treatment when curative surgery was not an option, whereas only three patients were started with adjusted calcium levels greater than 2.85 mmol/l and significant cognitive impairment. Two patients were started as a secondary treatment where curative surgery had failed and further surgery was not possible.
Conclusion: We would need to continue to work on our practices to meet the criteria set out by NHS England Clinical Commisioning Policy.
We have identified that vitamin D is not consistently checked and replaced prior to starting Cinacalcet.
Majority of patients were started on Cinacalcet as a primary treatment when curative surgery was not an option.
18 - 21 May 2019
European Society of Endocrinology