# Combination Treatment With Intravenous and Oral Calcimimetics for Secondary Hyperparathyroidism in Hemodialysis Patients Who Decline Parathyroidectomy

## TL;DR

This study shows that combining intravenous and oral calcimimetics can effectively lower parathyroid hormone levels in hemodialysis patients who refuse surgery for secondary hyperparathyroidism.

## Contribution

The study introduces a combination therapy of intravenous and oral calcimimetics as a non-surgical treatment for refractory SHPT in hemodialysis patients.

## Key findings

- Combination calcimimetic treatment significantly reduced plasma PTH levels in all patients.
- No gastrointestinal complications were reported, indicating good tolerability of the regimen.
- Two patients developed renal cancer, highlighting the need for long-term safety monitoring.

## Abstract

Background and aim: Secondary hyperparathyroidism (SHPT) is a common and serious complication in patients on hemodialysis (HD), leading to significant morbidity and mortality. Parathyroidectomy (PTx) is an established treatment for refractory SHPT, but many patients refuse this surgical option. This study evaluates the efficacy of combination treatment using intravenous and oral calcimimetics in managing SHPT in patients who decline PTx. This study aimed to assess the impact of combination calcimimetic treatment on plasma parathyroid hormone (PTH) levels, mineral metabolism, and clinical outcomes in patients on hemodialysis with SHPT who refuse PTx.

Methods: This retrospective study involved seven patients on HD with refractory SHPT who declined PTX. They were treated with various combinations of intravenous (etelcalcetide or upacicalcet), oral (cinacalcet or evocalcet) calcimimetics, and vitamin D receptor activators (VDRAs), with or without denosumab. Clinical outcomes, including changes in plasma PTH levels, mineral metabolism, and adverse events, were monitored over a period ranging from 10 to 100 months.

Results: Combination treatment significantly reduced plasma PTH levels in all patients (median reduction from 379 pg/mL to 193 pg/mL). No gastrointestinal complications were reported, confirming the tolerability of the regimen. However, two patients developed renal cancer, and one patient died from cardiovascular disease, highlighting the complex comorbidities in this population. These findings underscore the effectiveness of combination calcimimetics in managing SHPT in patients who refuse surgery, although careful monitoring for adverse events is necessary.

Conclusion: The combination of intravenous and oral calcimimetics is an effective therapeutic option for managing SHPT in patients on HD who refuse PTX. While promising, the long-term safety and potential risks of this approach, including the occurrence of malignancies, warrant further investigation in larger prospective studies.