Management of Diffuse Idiopathic Skeletal Hyperostosis (DISH)
The primary treatment for Diffuse Idiopathic Skeletal Hyperostosis (DISH) diagnosed on x-ray is symptom management with NSAIDs or COX-2 inhibitors as first-line therapy, with evaluation of response after 2-4 weeks. 1
First-Line Treatment Options
- NSAIDs/COX-2 inhibitors at maximum tolerated dosage:
- Options include: naproxen, indomethacin, ibuprofen, celecoxib, etoricoxib, piroxicam, and meloxicam
- Evaluate response after 2-4 weeks
- Monitor for gastrointestinal, renal, and cardiovascular adverse effects, especially in elderly patients
Second-Line Treatment Options
For patients who don't respond adequately to NSAIDs/COX-2 inhibitors:
- Intravenous bisphosphonates
- TNF-α inhibitors
- Evaluate response after 3-6 months
Bridging Therapy Options
- Short courses of oral prednisolone
- Intra-articular glucocorticoid injections for localized pain
Surgical Management
Surgery should be reserved for cases with:
- Severe functional impairment
- Neurological complications
- Failure of conservative management
Treatment Monitoring
Treatment success should be assessed through:
- Pain reduction
- Improved function
- Radiological assessment using MRI or CT combined with nuclear imaging
- Laboratory monitoring of inflammatory markers if previously elevated
Associated Conditions to Address
DISH frequently coexists with metabolic disorders that should be managed concurrently:
- Diabetes
- Obesity
- Hyperlipidemia
Special Considerations
- Patients with DISH have an increased risk of spinal fractures due to spinal rigidity combined with osteoporosis 2
- These fractures often involve all 3 spinal columns and can cause neurological deficits
- Clinical suspicion for fracture must be elevated in patients with DISH who experience trauma
- Early use of advanced imaging is crucial to facilitate timely diagnosis of fractures in these patients
The management approach should be tailored based on symptom severity, functional limitations, and presence of complications, with the goal of improving quality of life and preventing progression of the condition.