Should a patient with Paget's disease of the bone, elevated alkaline phosphatase (ALP) levels, and improved bone pain on ibuprofen (ibuprofen), plan to receive treatment prior to undergoing total hip arthroplasty (THA)?

From the Guidelines

For a patient with Paget's disease of bone (elevated alkaline phosphatase of 178 U/L) who is planning for total hip arthroplasty, treatment before surgery is recommended to reduce the risk of surgical complications and improve long-term bone health. The patient should receive bisphosphonate therapy, preferably zoledronic acid 5 mg as a single intravenous infusion, at least 2-3 months before surgery 1. Alternatively, oral alendronate 40 mg daily for 6 weeks or risedronate 30 mg daily for 2 months could be used.

• The goal of this preoperative treatment is to normalize alkaline phosphatase levels or reduce them by at least 50% before surgery.
• Additionally, the patient should receive calcium (1000-1500 mg daily) and vitamin D (800-1000 IU daily) supplementation during treatment to prevent hypocalcemia. While the patient's bone pain has improved with ibuprofen, treating the underlying Paget's disease is necessary for optimal surgical outcomes and long-term bone health.
• After surgery, periodic monitoring of alkaline phosphatase levels is recommended to assess disease activity and determine if additional treatment cycles are needed. It is also important to note that the provided guidelines for perioperative management of antirheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty do not directly apply to this patient's condition, as they focus on patients with inflammatory arthritis and systemic lupus erythematosus (SLE) 1.
• However, the general principle of optimizing the patient's condition before surgery to minimize the risk of complications is still relevant. The patient's current alkaline phosphatase level of 178 U/L, which is elevated, indicates active Paget's disease, and treatment is necessary to reduce the risk of surgical complications, including excessive bleeding, poor implant fixation, and heterotopic ossification.
• Therefore, initiating bisphosphonate therapy before surgery is the best approach to improve the patient's outcome and reduce the risk of complications.

From the FDA Drug Label

2.5 Treatment of Paget's Disease of Bone The recommended treatment regimen is 40 mg once a day for six months. 1.5 Treatment of Paget's Disease of Bone Alendronate sodium tablets, USP are indicated for the treatment of Paget's disease of bone in men and women. Treatment is indicated in patients with Paget's disease of bone who have alkaline phosphatase at least two times the upper limit of normal, or those who are symptomatic, or those at risk for future complications from their disease.

The patient has Paget's disease of bone with an alkaline phosphatase level of 178, which is within the normal range of 50-120 u/l, but the patient is symptomatic with bone pain that has improved with ibuprofen. Given the patient's condition and the fact that they are planning for total hip arthroplasty, treatment with alendronate may be considered to reduce the risk of future complications from Paget's disease. However, the decision to initiate treatment should be based on a thorough evaluation of the patient's individual risk factors and the potential benefits and risks of treatment 2, 2, 2. Key considerations include:

• The patient's alkaline phosphatase level is within the normal range
• The patient is symptomatic with bone pain
• The patient is planning for total hip arthroplasty
• The potential benefits and risks of treatment with alendronate.

From the Research

Patient Profile

• The patient has Paget's disease of the bone with an alkaline phosphatase level of 178 u/l, which is slightly elevated (normal range: 50-120 u/l).
• The patient experiences bone pain that has improved with ibuprofen.
• There are no palpable bony abnormalities or tenderness.
• The patient is planning to undergo total hip arthroplasty.

Treatment Approach

• According to 3, bisphosphonate therapy, specifically zoledronic acid, is the mainstay of treatment for Paget's disease of bone, but it should be reserved for symptomatic patients.
• 4 recommends treatment with a bisphosphonate for most patients with active Paget's disease who are at risk for further skeletal and extraskeletal complications.
• 5 suggests that bisphosphonates, particularly zoledronic acid, are recommended for the treatment of bone pain associated with Paget's disease.
• Given the patient's planned total hip arthroplasty, 6 and 7 provide insight into the outcomes and complications of this procedure in patients with Paget's disease, highlighting the importance of preoperative assessment and intraoperative considerations.

Considerations for Total Hip Arthroplasty

• 6 notes that rapid bone turnover in patients with Paget's disease may affect outcomes following total hip arthroplasty.
• 7 highlights the potential complications of total hip arthroplasty in patients with Paget's disease, including excessive bleeding, bone quality changes, and heterotopic bone formation.
• The patient's slightly elevated alkaline phosphatase level and improved bone pain with ibuprofen suggest that their Paget's disease may be relatively well-controlled, but careful consideration of their disease activity and bone quality is necessary when planning total hip arthroplasty.