New guidelines issued for chronic hypoparathyroidism treatment
European experts expand guidance on PTH replacement therapies
The European Society of Endocrinology (ESE) has issued updated treatment guidelines for adults with chronic hypoparathyroidism, introducing changes such as the redefinition of when the disease becomes chronic after surgery and expanded guidance on when to use parathyroid hormone (PTH) replacement therapies.
The recommendations were developed by a multidisciplinary team of experts chaired by Jens Bollerslev, MD, of the University of Oslo in Norway, and have already been endorsed by groups including the European Society of Endocrine Surgeons and the Endocrine Society of Australia.
“These guidelines have been developed as the management of hypoparathyroidism has changed since the first ESE clinical guideline was published in 2015, as has the knowledge on patient burden of the disease, and the understanding of morbidities,” Bollerslev said in an ESE press release. “The Revised Guideline is a true collaboration between clinical endocrinologists, methodologists, patient representatives, and the various disciplines involved in hypoparathyroidism such as nephrology and endocrine surgery.”
The recommendations were published in the European Journal of Endocrinology in the paper, “Revised European Society of Endocrinology Clinical Practice Guideline: Treatment of Chronic Hypoparathyroidism in Adults.”
Hypoparathyroidism most commonly arises as a complication of neck surgery
Hypoparathyroidism is marked by low levels of PTH, a signaling molecule that helps regulate calcium levels in the body. Without enough PTH, calcium levels drop and patients experience hypocalcemia, which drives most disease symptoms.
Hypoparathyroidism most commonly arises as a complication of neck surgery that damages the parathyroid glands, which are the organs responsible for making PTH.
The updated guidelines recommend considering a diagnosis of chronic hypoparathyroidism in individuals with persistent hypocalcaemia and abnormally low or normal PTH levels.
One of the most notable changes is a new definition of when postsurgical hypoparathyroidism becomes chronic: it now requires symptoms to persist for at least 12 months after surgery, rather than the previous six.
“In the original Guideline, the definition of chronic hypoparathyroidism was persisting post-surgery for six months or longer,” Bollerslev said. “After a systematic review of the literature, including 14 studies with almost 9,000 patients after neck surgery, the panel saw that the incidence of recovery of parathyroid function increased by almost 7.5% between six months and 12 months. So, in the Revised Guideline, we define chronic hypoparathyroidism 12 months or longer post-surgery.”
Guidelines provide more precise criteria for starting treatment after diagnosis
The guidelines also provide more precise criteria for starting treatment after diagnosis. For example, they note that treatment should be considered in patients with persistent low calcium levels, even if there are no apparent symptoms of hypocalcemia.
The guidelines also state that treatment of chronic hypoparathyroidism should be personalized and centered around improving a person’s well-being. The goal of management should be to optimize quality of life, minimize symptoms, improve long-term prognosis, and maintain calcium levels within or slightly below the normal range.
First-line treatment of chronic hypoparathyroidism continues to include dietary adjustments and supplements of calcium and vitamin D, which help the body absorb calcium.
While we currently do not recommend PTH replacement therapy during pregnancy, it might be considered for individual patients who are inadequately controlled by conventional therapy. This position may evolve as additional evidence on safety becomes available.
For people who remain poorly controlled, the guidelines expand guidance on the use of PTH replacement therapies, such as Yorvipath (palopegteriparatide), describing situations where switching may be appropriate and offering practical recommendations for transitioning therapies.
The guidelines also emphasize the importance of regularly monitoring calcium and PTH levels, with more frequent testing during treatment initiation or adjustment.
Finally, the guidelines include considerations for managing chronic hypoparathyroidism in special situations, such as during pregnancy. While PTH replacement is not generally recommended during pregnancy because of limited data, the guidelines note that its use may be considered in selected individuals with difficult-to-control disease. They also stress that recommendations may evolve as more evidence becomes available.
“While we currently do not recommend PTH replacement therapy during pregnancy, it might be considered for individual patients who are inadequately controlled by conventional therapy. This position may evolve as additional evidence on safety becomes available,” the expert panel wrote.
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