What is the management of osteitis pubis with erosive changes in a 65-year-old patient?

Management of Osteitis Pubis with Erosive Changes in a 65-Year-Old

For osteitis pubis with erosive changes in a 65-year-old patient, first-line treatment should begin with NSAIDs/COXIBs at maximum tolerated dosage, followed by intravenous bisphosphonates or TNF inhibitors if initial treatment fails, with treatment decisions guided by clinical symptoms and radiological evidence of inflammation. 1

Diagnostic Workup

• Imaging studies:

  • MRI is the preferred initial imaging modality to assess bone marrow edema and erosive changes 2, 1
  • Consider [99mTc]Tc-HDP SPECT/CT as an alternative or complementary imaging method 2, 1
  • Whole-body imaging should be considered to map all clinically silent but radiologically active lesions 1

• Laboratory tests:

  • Check inflammatory markers (ESR, CRP) - may be elevated but are not specific 1
  • Rule out infection through appropriate cultures if fever or significantly raised inflammatory parameters are present 2

• Consider bone biopsy only if there is suspicion of malignancy or infectious osteomyelitis 1

Disease Activity Assessment

Categorize the patient based on clinical symptoms and radiological findings 2:

1. Active CNO: Corresponding clinical symptoms (pain) AND radiological disease activity (bone marrow edema/increased tracer uptake) - initiate treatment
2. Inactive CNO: Neither clinical symptoms nor radiological disease activity - no treatment needed
3. Probable inactive CNO: Clinical symptoms WITHOUT radiological disease activity - investigate other causes of pain
4. No clinically relevant CNO activity: Radiological disease activity WITHOUT clinical symptoms - consider treatment in shared decision

Treatment Algorithm

First-Line Treatment 2, 1

• NSAIDs/COXIBs at maximum tolerated dosage:
  • Options include naproxen, indomethacin, ibuprofen, celecoxib, etoricoxib, piroxicam, or meloxicam
  • Evaluate response at 2-4 weeks
  • If sufficient response: continue and re-evaluate at 12 weeks
  • If insufficient response: consider NSAID rotation or advance to second-line treatment

Adjunctive First-Line Options 2, 1

• Patient education and lifestyle modifications
• Physical therapy to maintain mobility and strength
• Consider short courses of oral prednisolone (e.g., 20mg daily for 5-7 days) as bridging therapy
• Consider local glucocorticoid injections for focal pain

Second-Line Treatment 2, 1

If NSAIDs/COXIBs fail after 2-4 weeks:

• Intravenous bisphosphonates (first choice):
  • Pamidronate: 60mg IV every 3 months
  • Zoledronate: 5mg IV once yearly
  • Evaluate response at 3-6 months

OR

• TNF inhibitors:
  • Options include infliximab, etanercept, adalimumab, golimumab, or certolizumab
  • Evaluate response at 3-6 months

If sufficient response: continue and re-evaluate at 6-12 months If insufficient response: switch to the alternative second-line treatment or consider combination therapy

Third-Line Treatment 2

• Refer to specialized center for additional treatment options if both second-line treatments fail

Special Considerations for Elderly Patients

• In the 65-year-old population, carefully monitor for NSAID-related adverse effects (GI, renal, cardiovascular)
• Consider gastroprotection with proton pump inhibitors when using NSAIDs
• Assess bone mineral density before initiating bisphosphonates
• Monitor for bisphosphonate-related adverse effects including hypocalcemia and osteonecrosis of the jaw

Surgical Management

• Surgery is rarely required for non-athletic patients with osteitis pubis 3
• Consider surgical intervention only when all conservative measures have failed and pain remains disabling 4
• Surgical options may include:
  • Wedge-shaped resection of the symphysis pubis with autologous bone grafting and dual plating 4
  • Arthrodesis in severe cases 3

Treatment Response Evaluation

• Assess treatment response primarily based on clinical measures (pain reduction, improved function) 2, 1
• Integrate radiological measures (reduction in bone marrow edema or tracer uptake) 2
• Consider biochemical measures if previously elevated 1

Prognosis

• Most non-athletic patients with osteitis pubis respond well to conservative treatment 3
• With proper diagnosis and treatment, prognosis for recovery is generally excellent 1
• Patients should be monitored for potential complications such as progressive structural damage or functional limitations 2

Common Pitfalls to Avoid

• Failing to rule out infectious causes before diagnosing chronic non-bacterial osteitis
• Relying solely on MRI findings for treatment decisions, as abnormal findings can be present in asymptomatic individuals 5
• Premature advancement to surgical intervention before exhausting conservative options
• Inadequate duration of first-line therapy before moving to second-line options