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Calcimimetic (Calcium-sensing Receptor Agonist) Pregnancy: Avoid — potential fetal hypocalcaemia from maternal calcium-sensing receptor activation. Seek specialist advice.

Cinacalcet

Brand names: Mimpara

Adult dose

Dose: Secondary hyperparathyroidism in dialysis: 30mg OD initially; titrate every 2–4 weeks by 30mg increments to a maximum of 180mg OD (target PTH 2–9× upper limit of normal per KDIGO). Primary hyperparathyroidism (inoperable): 30mg BD, titrated to max 90mg QDS (specialist use).
Route: Oral (take with food or shortly after a meal)
Frequency: Once daily (secondary HPT); BD to QDS (primary HPT)
Max: 180mg OD (dialysis); 360mg daily (primary HPT — divided doses)
Allosteric activator of the calcium-sensing receptor (CaSR) on parathyroid cells → suppresses PTH secretion. Reduces PTH without raising calcium (unlike vitamin D analogues which raise both). Indicated when PTH is uncontrolled on vitamin D analogues or calcium is too high to add more vitamin D. Monitor calcium closely — risk of hypocalcaemia.

Paediatric dose

Route: Oral
Frequency: Once daily
Max: Individualised
Not licensed under 18 years. Seek specialist paediatric renal/endocrinology opinion.

Dose adjustments

Renal

Primarily used in dialysis patients — no adjustment needed for dialysis. Not recommended in non-dialysis CKD (risk of hypocalcaemia, no outcome data).

Hepatic

Moderate-severe hepatic impairment: increased cinacalcet exposure — monitor carefully; dose reduction may be needed.

Clinical pearls

  • EVOLVE trial: cinacalcet did not significantly reduce primary endpoint of cardiovascular death/events in dialysis patients — used for biochemical control of secondary HPT, not proven cardiovascular mortality benefit
  • Hypocalcaemia monitoring: check serum calcium within 1 week of starting and within 1 week of any dose change — symptomatic hypocalcaemia (paraesthesia, muscle cramps, tetany, seizures) can occur
  • Nausea management: take with largest meal of the day; do not crush tablets (whole tablet absorption only)
  • Avoid over-suppression of PTH: target range in dialysis is 2–9× ULN (KDIGO) — if PTH falls below 150 pg/mL, reduce dose

Contraindications

  • Hypocalcaemia (serum calcium <2.1 mmol/L) — correct before starting
  • Hypersensitivity to cinacalcet

Side effects

  • Hypocalcaemia (most important — can cause seizures, QT prolongation, cardiac arrhythmias)
  • Nausea and vomiting (very common — most common reason for discontinuation; take with food)
  • Diarrhoea
  • Myalgia
  • QT prolongation (secondary to hypocalcaemia)
  • Adynamic bone disease (over-suppression of PTH)

Interactions

  • Strong CYP2D6 inhibitors (fluoxetine, paroxetine, bupropion) — increase cinacalcet levels significantly; reduce dose or monitor closely
  • CYP3A4 inhibitors (ketoconazole) — increase exposure
  • Drugs metabolised by CYP2D6 (tricyclic antidepressants, some antipsychotics) — cinacalcet inhibits CYP2D6; increased levels of these drugs

Monitoring

  • Serum calcium (1 week after start or dose change; monthly when stable)
  • PTH level (every 1–3 months)
  • Phosphate
  • ECG if symptomatic (QT prolongation from hypocalcaemia)

Reference: BNFc; BNF 90; NICE TA117 (Cinacalcet in CKD); KDIGO CKD-MBD Guidelines 2017; EVOLVE Trial (NEJM 2012). Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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