Internal Medicine

0521779407-17 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:18

Paget Disease 1123

■Specific Diagnostic Tests

➣Bone biopsy usually not indicated

➣Audiogram if skull involvement

Imaging

■Plain films of affected bone: osteolysis early, then thickened sclerotic

bone

■Radionuclide bone scan highly sensitive for active disease

differential diagnosis

■Osteoblastic metastases

➣Sclerotic bone disorders (generally rare)

management

What to Do First

■Establish diagnosis

General Measures

■NSAIDs for managing secondary degenerative arthritis

specific therapy

■Bisphosphonates:

➣Treatment of choice

➣Alendronate, risedronate, tiludronate taken fasting with 6 oz

water only

➣Wait 30 min in upright position before taking other medications

or food

➣When oral therapy contraindicated or not tolerated: intravenous

pamidronate

■Calcitonin:

➣SC injection or nasal spray

➣Rapidly diminishes disease activity

➣Less effective than bisphosphonates

■Side Effects & Contraindications

■Bisphosphonates:

➣Side effects: oral-esophageal irritation,∼10% of patients; IV:

fever, arthralgias; if intolerant to one, try another bisphospho-

nate

Rare occurrence of osteonecrosis of jaw, particularly with IV

bisphosphonates

➣Contraindications: previous severe intolerance, intestinal mal-

absorption due to disease or surgery