Treatment of Diffuse Idiopathic Skeletal Hyperostosis (DISH) in Elderly Males
Treatment for DISH in elderly males should focus on symptomatic relief with NSAIDs for pain and stiffness, physical therapy to maintain mobility, and aggressive management of associated metabolic conditions including diabetes, hypertension, and dyslipidemia, as no disease-modifying therapies currently exist. 1, 2
Understanding DISH and Its Clinical Significance
DISH is a systemic bone-forming condition characterized by calcification and ossification of ligaments and entheses, most commonly affecting men over 50 years of age. 2 The condition differs fundamentally from osteoarthritis and requires a distinct management approach. 1 Importantly, DISH increases the risk of unstable spinal fractures and is strongly associated with metabolic syndrome, coronary disease, and respiratory complications. 3
Primary Treatment Strategy: Symptomatic Management
Pain and Stiffness Control
- NSAIDs are the cornerstone of pharmacologic therapy for managing pain and stiffness in DISH patients. 1, 4
- Treatment should aim for symptomatic relief rather than disease modification, as no therapies currently exist to halt or reverse the ossification process. 1
- Modified diet may be necessary if dysphagia develops from cervical spine involvement. 4
Physical Therapy and Lifestyle Modifications
- Physical exercise programs should be prescribed to maintain range of motion and prevent further stiffness. 1
- Focus on flexibility exercises and range-of-motion activities to counteract the progressive limitation caused by ligamentous ossification. 1
- Weight management is critical given the strong association with obesity. 3
Critical: Management of Associated Metabolic Disorders
Aggressive control of metabolic comorbidities is essential and may prevent disease progression. 1 DISH shows strong associations with:
- Diabetes mellitus and hyperinsulinemia - requires tight glycemic control 1, 3
- Hypertension - needs standard antihypertensive management 1, 3
- Hyperlipidemia - warrants lipid-lowering therapy 1
- Hyperuricemia - may require uric acid-lowering agents 1
The rationale for treating these conditions extends beyond general health: controlling metabolic disorders may reduce morbidities and potentially slow DISH progression. 1
Monitoring for Complications
Spinal Fracture Risk
- Elderly males with DISH have significantly increased risk of unstable spinal fractures. 3
- Counsel patients about fall prevention strategies
- Consider bone density assessment, as osteoporosis management principles may apply (vitamin D 800-1,000 IU daily and calcium 1,000-1,200 mg daily). 5
Dysphagia Screening
- Cervical DISH can cause dysphagia through anterior osteophyte compression at C3-C4 levels. 4
- Screen for swallowing difficulties, particularly weight loss or choking episodes. 4
- Important caveat: Avoid routine endoscopy in patients with known cervical DISH due to perforation risk. 4
- If dysphagia is suspected, use video fluoroscopy or barium swallow rather than endoscopy for diagnosis. 4
Cardiovascular Assessment
- DISH patients require cardiovascular risk stratification given strong associations with coronary and aortic disease. 3
- Screen for atherosclerosis and manage cardiovascular risk factors aggressively. 3
When Conservative Management Fails
- Surgical intervention may be considered for severe dysphagia from cervical osteophytes when conservative measures (NSAIDs, diet modification) fail. 4
- Percutaneous endoscopic gastrostomy may be necessary in patients unfit for surgery who cannot maintain nutrition. 4
- Orthopedic consultation for management of spinal fractures, which are more complex in DISH patients. 3
Common Pitfalls to Avoid
Do not confuse DISH with psoriatic arthritis or ankylosing spondylitis - DISH typically shows flowing ossification along the anterolateral spine without sacroiliac involvement and has normal inflammatory markers. 6
Do not perform upper endoscopy as first-line investigation for dysphagia in patients with known or suspected cervical DISH due to perforation risk. 4
Do not neglect metabolic screening - the presence of DISH should trigger comprehensive metabolic evaluation even if asymptomatic. 1, 3
Do not assume DISH is benign - while often asymptomatic, it carries significant fracture risk and cardiovascular associations requiring active management. 3