A 73-year-old male presents with pain and restriction of movement in his left hip joint for the last six months. He has been taking over-the-counter acetaminophen two to three times a day, although this does not give any significant relief from this pain. His past medical history is significant for type II diabetes and hypertension. He is currently on metformin, hydrochlorothiazide, and atenolol. His father has hypertension and gout. He has a 30-pack-year history of smoking, but he quit smoking 10 years ago. He has a history of alcohol abuse during his early 20’s. Currently, he drinks a glass of wine over the weekends. His physical examination reveals restricted movement in his left hip joint, with pain on passive flexion. The rest of the physical examination is unremarkable. X-ray of his left hip joint and pelvis reveals thickening of outer cortex of his left proximal femur with mild bowing. Sclerotic lesions are also present on the left ischial bone. Technetium bone scan shows an increased uptake in the frontal bone, left scapula, left ischium, and whole of his left proximal femur. Routine lab results including creatinine and calcium levels are normal. What is the most appropriate treatment for this patient?
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- A. Alendronate [ 45%]
- B. Calcitriol [11 %]
- C. Radiotherapy [26%]
- D. Ibuprofen [5%]
- E. Prednisone [11 %]
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Explanation:
Treatment of Paget’s disease is indicated when patients have intolerable pain, involvement of weight-bearing bones, neurological involvement, hypercalcemia, hypercalcinuria, and congestive heart failure. Several bisphosphonates (alendronate, risedronate, and pamidronate) are approved for the treatment of Paget’s disease. Six months of treatment with oral alendronate and two months of treatment with oral risedronate lead to sustained remission in a large number of patients. IV pamidronate can be used in patients with contraindications to the use of oral bisphosphonates. Treatment with older bisphosphonates (etidronate) and calcitonin are not currently used for management of Paget’s disease.