If PTH levels remain elevated despite these measures, active vitamin D analogues (such as calcitriol) may be used in lieu of ergocalciferol; however, these agents may cause marked elevation of serum phosphate and calcium levels, which must continue to be carefully monitored. In patients with more advanced disease, calcimimetics (i.e., cinacalcet) may be used, although they are only approved for those receiving dialysis. Calcimimetics bind to the calcium sensing receptor on the parathyroid glands, suppressing PTH release, but they are associated with an increased risk of hypocalcemia.

If PTH levels are oversuppressed, patients can develop adynamic bone disease, which is also associated with increased risk of fracture. This disorder is becoming increasingly common as vitamin D analogues are more widely used to suppress PTH. If the PTH level falls below 100 pmol/L, the risk of adynamic bone disease is high, and dosages of vitamin D analogues and calcium-based phosphate binders should be reduced.

Finally, osteomalacia, another form of low bone turnover disease, can be seen in some patients due to vitamin D deficiency or aluminum toxicity. With the near elimination of aluminum-based binders in clinical practice, however, aluminum toxicity is now uncommon.