How to manage gastrointestinal (GI) manifestations in patients with Paget's disease?

Management of Gastrointestinal Manifestations in Paget's Disease

For patients with Paget's disease experiencing gastrointestinal manifestations, metoclopramide is the first-line treatment for symptoms such as delayed gastric emptying, nausea, and dyspepsia, while constipation should be managed prophylactically with stimulant laxatives. 1

Common GI Manifestations in Paget's Disease

Gastrointestinal symptoms in Paget's disease can significantly impact quality of life and may include:

• Postprandial abdominal pain and bloating
• Multiple bowel movements and chronic/intermittent diarrhea
• Nausea and vomiting
• Early satiety
• Difficulty gaining weight
• Delayed gastric emptying

These symptoms typically begin in adolescence, sometimes before age 10, and are generally more frequent and appear earlier in males 1.

Diagnostic Approach

When evaluating GI manifestations in Paget's disease:

1. Focus on bowel habits, weight changes, and dietary aspects
2. Consider radiographic or endoscopic evaluation when symptoms persist
3. Rule out other causes of GI symptoms, particularly in patients receiving bisphosphonate therapy

Management Algorithm

1. Motility Issues and Dyspepsia

• First-line: Metoclopramide for delayed gastric emptying and dyspepsia 1

  • Strongest evidence supports metoclopramide for antiemesis unrelated to chemotherapy 1
  • Consider as a prokinetic agent if gastroparesis is suspected 1

• Second-line: H2-blockers for persistent dyspepsia 1

2. Constipation Management

Constipation is common in patients with chronic diseases and requires proactive management:

• Prophylactic approach: Start stimulant laxatives (e.g., senna) to increase bowel motility 1

  • Evidence suggests senna alone is effective; stool softeners may not be necessary 1

• For persistent constipation:

  1. Add bisacodyl 10-15 mg, 2-3 times daily (goal: one non-forced bowel movement every 1-2 days) 1
  2. For impaction: glycerine suppositories or manual disimpaction 1
  3. If constipation persists: add rectal bisacodyl once daily or oral polyethylene glycol, lactulose, magnesium hydroxide, or magnesium citrate 1

3. Nutritional Considerations

Patients with Paget's disease receiving bisphosphonate therapy require special attention to calcium and vitamin D status:

• Before bisphosphonate therapy:

  • Correct hypocalcemia 2
  • Ensure adequate vitamin D levels 2, 3
  • Provide calcium supplementation 2, 4

• During and after bisphosphonate therapy:

  • Continue calcium and vitamin D supplementation to prevent hypocalcemia 5, 4
  • Monitor for secondary hyperparathyroidism, which can occur with bisphosphonate treatment 3

Special Considerations for Bisphosphonate Therapy

Bisphosphonates are the mainstay of treatment for Paget's disease but can impact GI function:

• Risk of upper GI irritation: Use caution in patients with active upper GI problems (Barrett's esophagus, dysphagia, esophageal diseases, gastritis, duodenitis, or ulcers) 2

• Prevention of hypocalcemia:

  • Educational strategies for both physicians and patients about calcium and vitamin D supplementation can significantly reduce the risk of hypocalcemia following bisphosphonate infusion 4
  • Monitor serum calcium levels, especially after initiating therapy 6, 3

• Administration guidelines to minimize GI side effects:

  • Take oral bisphosphonates at least 30 minutes before first food/beverage with plain water only 2
  • Remain upright for at least 30 minutes after taking 2
  • Never take at bedtime or before arising 2

Monitoring and Follow-up

• Regular assessment of GI symptoms and their impact on quality of life
• Monitoring of calcium and vitamin D levels, particularly in patients on bisphosphonate therapy
• Evaluation of nutritional status, including weight and dietary intake
• Adjustment of therapy based on symptom response

Pitfalls to Avoid

1. Failing to correct calcium and vitamin D deficiency before starting bisphosphonate therapy, which can lead to severe hypocalcemia 6, 3

2. Overlooking the potential for "hungry bone syndrome" in patients with extensive Paget's disease who receive potent anti-resorptive therapy 6

3. Inadequate management of constipation, which can significantly impact quality of life

4. Improper bisphosphonate administration, which can increase the risk of esophageal adverse effects 2

5. Neglecting to continue calcium and vitamin D supplementation after achieving normocalcemia, which may prolong secondary hyperparathyroidism 3