Skip to Main Content

++

Paget disease (osteitis deformans)

++ Features
++

  • 95% asymptomatic (M:F ratio = 2:1)

  • Symptoms may include joint pain and stiffness (e.g. hips, knees); bone pain (usually spine); deformity; headache; deafness.

  • Bone pain is typically deep and aching: may be worse at night.

  • Signs may include deformity, enlarged skull—‘hats don't fit any more’, bowing of tibia, waddling gait.

  • Bones most commonly affected (in order) are pelvis, femur, skull, tibia, vertebrae.

++ Diagnosis
++

  • Raised serum alkaline phosphatase (often very high >1000 U/L)

    Note: Calcium and phosphate normal.

  • Plain X-ray: dense expanded bone best seen in skull and pelvis

    Note: Can mimic prostatic secondaries so every male Pagetic patient should have PR and PSA test.

  • Bone isotopic scans: useful in locating specific areas

++ Treatment
++

The two major goals are relief of pain and prevention of long-term complication (e.g. deafness, deformities).

++

Localised and asymptomatic disease requires no treatment.

++

Three groups of drugs currently available:

++

  • the bisphosphonates (i.e. etidronate, pamidronate, alendronate, tiludronate)—first line but serum Ca and vitamin D and eGFR must be OK

  • the calcitonins (salmon, porcine, human)—used if bisphosphonates contraindicated (e.g. adverse effects)

  • various antineoplastic agents (e.g. mithramycin)

+
++

Bisphosphonates are first-line agents (oral agents taken on an empty stomach)—one of:

++

  • alendronate 40 mg (o) daily for 6 mths (oesophagitis can be problematic)

  • pamidronate disodium 60 mg IV infused over 4 hrs (usually preferred option); repeated doses may rarely be required according to disease activity

  • risedronate 30 mg (o) daily for 2 mths

  • tiludronate 400 mg (o) daily for 3 mths

  • zoledronic acid 5 mg IV, once yearly

+
++

Pain and its management

++

Pain is the capital symptom of humans—the great hallmark of disease—the signal par excellence to the patient and doctor that all is not well. In general terms, the origin of conscious pain can be subdivided into three broad types—nociceptive, neurogenic or psychogenic.

++

  1. Nociceptive pain is pain arising from stimulation of superficial or deep tissue pain receptors (nociceptors) from tissue injury or inflammation. It requires an intact nervous system. Nociception is stimulation of peripheral nociceptors (i.e. nerve endings sensitive to a noxious stimulus).

  2. Neuropathic pain is pain caused or initiated by a primary lesion or disease or dysfunction (i.e. damage) in the peripheral or central nervous system. It can be subdivided into central pain, when the primary lesion is in the central nervous system (e.g. CVA, MS) or peripheral pain, e.g. post-herpetic neuralgia, peripheral neuropathy, trigeminal neuralgia.

  3. Psychogenic pain is pain arising in the absence of any discernible injury and where the predominant aetiology is psychological or psychiatric.

++ Analgesics in common use
++

  • Paracetamol: oral use

  • Aspirin: oral

  • Other NSAIDs:

    • non-selective inhibitors of COX-1 and COX-2 (e.g. ibuprofen, naproxen, indomethacin, ketorolac—oral + ...

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.

Ok

About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

Murtagh Collection Full Site: One-Year Subscription

Connect to a suite of general practice resources from one of the most influential authors in the field. Learn the breadth of general practice, including up-to-date information on diagnosis and treatment, as well as key clinical skills like communication.

$145 USD
Buy Now

Pay Per View: Timed Access to all of Murtagh Collection

48 Hour Subscription $34.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.