Pharmacological Management of Secondary Hyperparathyroidism in Dialysis Patients: A Narrative Review of Calcimimetics, Vitamin D Analogs, and Phosphate Binders.

Secondary hyperparathyroidism (sHPT) is a prevalent complication of end-stage renal disease, driven by phosphate retention, vitamin D deficiency, hypocalcemia, and calcium-sensing receptor dysregulation. Despite international guidelines, optimal biochemical control remains challenging in real-world practice. This narrative review synthesizes current evidence on the pharmacological management of sHPT in dialysis patients, with attention to the underrepresented Middle Eastern and Gulf Cooperation Council (GCC) context. A narrative review was conducted using PubMed and Scopus, identifying original clinical studies, randomized controlled trials, and observational cohorts examining calcimimetics, vitamin D analogs, and phosphate binders in dialysis patients with sHPT. In total, 22 studies were included. Calcimimetics, particularly cinacalcet, reduce parathyroid hormone (PTH) by approximately 43% in hemodialysis patients without raising serum calcium, though hypocalcemia and gastrointestinal adverse effects limit tolerability. Intravenous etelcalcetide offers superior PTH suppression with improved gastrointestinal tolerability and eliminates oral adherence challenges through supervised dialysis-circuit administration. A large trial demonstrated no mortality benefit despite sustained PTH lowering. Vitamin D analogs suppress PTH gene transcription but carry a narrow therapeutic window with risks of hypercalcemia and hyperphosphatemia. Phosphate binders address the primary upstream driver of sHPT; non-calcium-based agents such as sevelamer offer cardiovascular advantages but impose a pill burden contributing to nonadherence rates of 22-74%. Novel agents including tenapanor offer complementary phosphate-lowering mechanisms with substantially reduced pill burden. Combination therapy allows dose reduction of individual agents while optimizing biochemical outcomes. Evidence from Middle Eastern and GCC dialysis populations is virtually absent. Pharmacological management of sHPT requires individualized, guideline-informed combination therapy. A critical evidence gap exists in the GCC region, where diabetic nephropathy dominance, endemic vitamin D deficiency, and lower calcimimetic utilization may limit generalizability of existing trial data. Locally conducted research is urgently needed.