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FOLLOW UP

An assessment of the response to treatment for Paget's disease should take place between 3 and 6 months after treatment has been completed. 

An annual ALP can help monitor the condition.

CALCITONIN

In cases where bisphosphonates are not recommended, calcitonin injections may be considered to treat bone pain in Paget’s disease.

DIAGNOSIS

The most widely used biochemical marker to aid diagnosis of PDB is serum total alkaline phosphatase (ALP), which is typically elevated in active PDB. It should be noted that Paget's disease can be active and yet the alkaline phosphatase (ALP) may remain within the normal range, particularly if the area involved is small.

The condition has characteristic features on x-ray (summarised in Box 1). Individually, these features are not specific, but when they occur in combination, they are usually diagnostic. 

PAGET'S ARTICLES OF INTEREST

When and Why GPs should Refer to a Specialist

POTENTIAL COMPLICATIONS

The overall frequency with which complications occur in PDB is unknown but when they occur, surgical treatment is often required. Medical treatment with bisphosphonates is seldom effective at treating complications of Paget’s disease when they are established. 

WHO NEEDS TREATMENT?

Decisions to treat Paget’s disease should be made by a specialist, on an individual basis. 

CLINICAL GUIDELINE

Paget's Guideline

A clinical Guideline, for the Diagnosis and Management of Paget’s Disease of Bone in Adults, was commissioned by the Paget's Association and published in 2019, in the Journal of Bone and Mineral Research. It has been endorsed by the European Calcified Tissues Society, the International Osteoporosis Foundation, the American Society of Bone and Mineral Research, the Bone Research Society (UK), and the British Geriatric Society. 

CASE HISTORIES

Case 1

A 67-year-old man with pain in his right hip

Presenting Complaint
A 67-year-old man attended his GP complaining of pain in his right hip. It was present at rest and became slightly worse on walking. His general health was good. He was taking lisinopril 10mg daily for hypertension; atorvastatin 10mg daily for high cholesterol; and paracetamol 1-2g daily for pain.
Investigations

RISEDRONATE

Risedronate

  • Intravenous treatment with zoledronic acid is usually the first consideration, as it acts quicker and lasts longer, however, treatment can be given orally using Risedronate.

  • The most commonly used oral treatment is 30mg of risedronate sodium, daily, for two months.

  • If necessary, the course can be repeated. 

PAMIDRONATE

Pamidronate

Pamidronate is an effective treatment but has largely been superseded by zoledronate (zoledronic acid) which lasts longer and is easier to administer.

Pamidronate is given in several doses, intravenously and repeated when necessary, depending on symptoms. Doses can vary, but commonly 60mg is given by an infusion and this is repeated on 3 consecutive days.

Pamidronate: given intravenously over 2-4 hours.  Dosage (60 – 90 mg) and frequency will depend on the severity of symptoms.

 

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