From the Guidelines
Paget's disease should be treated with bisphosphonates, specifically zoledronic acid or oral options like alendronate, to slow bone turnover and prevent complications, as supported by the most recent and highest quality studies 1.
Treatment Overview
The treatment of Paget's disease focuses on relieving symptoms, preventing complications, and improving quality of life. Bisphosphonates are the primary treatment option, with zoledronic acid being the most effective due to its potent inhibition of osteoclast activity.
- Zoledronic acid (5mg IV once) is a highly effective treatment option for Paget's disease, as it significantly reduces bone turnover and alleviates symptoms.
- Oral bisphosphonates like alendronate (40mg daily for 6 months) or risedronate (30mg daily for 2 months) are alternative treatment options, although they may not be as potent as zoledronic acid.
Supporting Evidence
The use of bisphosphonates in treating Paget's disease is supported by studies, including the K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease 1. These guidelines highlight the effectiveness of bisphosphonates in increasing bone mass and preventing fractures in patients with osteoporosis, which is also relevant to Paget's disease.
Additional Considerations
Adequate calcium (1000-1500mg daily) and vitamin D (800-1000 IU daily) supplementation should accompany bisphosphonate treatment to support bone health. Pain management may include NSAIDs or acetaminophen, and regular monitoring with alkaline phosphatase levels helps assess disease activity and treatment response. Surgery may be necessary for complications like fractures or severe joint damage.
From the Research
Diagnosis of Paget's Disease
- Paget's disease of bone is characterized by focal increased bone remodeling activity, resulting in sclerotic or lytic lesions and poor bone quality at one or more sites 2
- Diagnosis is through plain film imaging, with radionuclide bone scan to determine the extent 2
- Biochemical evaluation of a patient should be done using serum total ALP (alkaline phosphatase) or with the use of a more specific marker of bone formation: PINP (intact N-terminal type 1 procollagen propeptide) or CTX (cross-linked C-telopeptide) 3
Treatment of Paget's Disease
- Bisphosphonates are the mainstay of the treatment of Paget's disease of bone (PDB) 4, 2, 5
- Treatment with a potent bisphosphonate is indicated in patients with Paget's disease who have symptoms likely to respond to reduced bone turnover at pagetic sites 5
- A single dose of 5 mg i.v. zoledronate is the current standard therapy for Paget's disease 2, 6, 3
- Oral bisphosphonates, such as alendronate and risedronate, are less potent than zoledronic acid but can still achieve remission in a large proportion of patients 4, 5, 6
Management and Follow-up
- Measurement of total ALP or other baseline disease activity markers at 6 to 12 weeks after treatment is an acceptable and cost-effective option to assess response to treatment 3
- Maximum suppression of high bone turnover may require measurement at 6 months after administration 3
- Biochemical follow-up is recommended to be used as a more objective indicator of relapse rather than symptoms 3
- The prolonged response after zoledronate treatment should be assessed every 1-2 years after normal bone turnover, while with less potent drugs, every 6 to 12 months is appropriate 3