In addition, parathyroidectomy is a cost P-glycoprotein effective procedure. Despite these benefits, parathyroidectomies are declining, particularly in developed countries.20 The rate of referrals at our institution has dropped by more than 85% since the introduction of cinacalcet into clinical practice. When comparing the biochemical parameters prior to either intervention, both cohorts had equally severe metabolic disturbances. This may potentially imply that increasingly, patients with severe 2HPTH who would have previously undergone surgery to improve biochemical control and longterm outcome are now being treated with cinacalcet. When cinacalcet became available in our hospital, patients were given a choice between surgery and cinacalcet by the renal physicians. Some of the reasons behind these observed changes in the management of 2HPTH included the relatively high number of patients declining the option for surgery that were otherwise anesthetically appropriate. Ten patients were placed on cinacalcet 5-alpha-reductase therapy as an interim measure while awaiting parathyroidectomy, of these, 60% opted to continue cinacalcet therapy because of symptomatic improvement.
Three patients were considered anesthetically unfit for surgical Gamma Secretase intervention. Most patients in the surgical cohort were operated on before cinacalcet became so widely available in our trust. Initial results of randomized placebo controlled trials involving cinacalcet have been extremely promising, providing strong evidence that the addition of cinacalcet to conventional medical therapy effectively reduces PTH.21 23 There is now some evidence that the better biochemical control associated with the treatment of cinacalcet has been translated into improved longer term outcomes, with several small studies reporting reduced rates of fractures, cardiovascular hospitalization, and improvement in self reported physical function and diminished pain.24,25 However, further studies are needed to establish a more definitive evidencebased role of cinacalcet. Cinacalcet was a well tolerated drug with minimal side effects. The most commonly encountered complication was gastrointestinal related nausea and vomiting. The level of response was variable Acadesine between patients and did not appear to be associated with severity of disease.
However, 15% of patients in our study failed to demonstrate any response to the drug, necessitating referral for parathyroidectomy. There remains little debate that both surgery and cinacalcet are superior to conventional medical management. These methods of treatment are safe and effectively lower the PTH without predisposing patients to hypercalcemia and hyperphosphatemia. Patients with ESRF and uncontrolled 2HPTH now have alternative options available to them, but surgical intervention should continue to be offered as an contrary effective and proven strategy of management in this important condition. In the era of medical parathyroidectomy, a therapeutic trial of cinacalcet should be reserved for patients unfit or refusing surgery and patients awaiting surgical parathyroidectomy. Conclusion With the introduction of cinacalcet, the role of surgery is less clear. Patients with uncontrolled 2HPTH who would have previously undergone surgery are now being trialed on cinacalcet instead. In our study.