Little evidence exists on treating secondary hyperparathyroidism (SHPT) in adults older than 65 years. In a new review published in Drugs & Aging, the authors suggest nephrologists continue to follow disease-centered guidelines, but incorporate a holistic evaluation of patients and their particular needs.

“Treatment of SHPT in the elderly should consider the many peculiarities of aging in terms of physiopathology, quality of life, symptoms, subjective perception of disease, drug load, and the modifying effect of treatment on disease-related outcomes,” Mario Cozzolino, MD, PhD, of St. Paul Hospital in Milan, Italy, and colleagues stated. The best treatment of SHPT in the elderly, however, remains uncertain, they noted.

Older renal patients have higher risks for cardiovascular disease, bone fractures, and mortality than younger patients. But they also tend to have lower parathyroid hormone (PTH) levels, lower risk of dietary phosphate overload, and higher risk for vitamin D deficiency. Better control of mineral metabolism may stem from older patients’ lower protein intake, predisposition to low bone turnover, and close follow-up in hospital settings.

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Taken together, SHPT treatment is reasonable for these patients. Observational studies have shown that older adults benefit from calcimimetics and parathyroidectomy.

Clinicians should consider a patient’s morbidity, frailty, and personal goals for shared decision-making process, according to the authors. Providers can globally evaluate a patient’s mental and functional status and social support system. They can elicit a patient’s subjective goals based on symptoms, mental and physical status, and social roles and devise a strategy to attain those goals. Survival may not always be a patient’s top priority.

Clinicians can also assess risks for falls and fractures, prescribe nutritional vitamin D, and treat SHPT to reduce the risk for bone fractures and cardiovascular problems. Curbing SHPT along with hyperphosphatemia also involves nutritional counseling for adequate calorie and protein intake and selection of the most tolerable and effective phosphate binder, calcimimetic, and vitamin D receptor activator.

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Galassi A, Ciceri P, Fasulo E, et al. Management of secondary hyperparathyroidism in chronic kidney disease: A focus on the elderly. Drugs Aging. doi:10.1007/s40266-019-00696-3