Treatment

The main aims of treatment would be to:

• eliminate bone pain
• normalize serum total alkaline phosphatase with prolonged remission
• heal radiographic osteolytic lesions
• restore normal lamellar bone
• prevent recurrence and complications (1)

The indications for treatment are outlined in the linked item.

Supportive therapy

• pain arising due to nerve compression and osteoarthritis may benefit from
  • simple analgesics, nonsteroidal anti-inflammatory agents or opioid analgesia (individually or in combination)
  • addition of low-dose tricyclic antidepressant therapy to an analgesic regimen may be usefull in some patients
  • physical methods of pain control could be helpful e.g. - physiotherapy, hydrotherapy (2)
• shoe lifts, canes, orthotics, or physical therapy - for difficulties arising due to bowing of the lower limbs, gait disturbances, or spinal stenosis
• educating people on prevention of falls and fractures (including avoiding heavy lifting for patients with vertebral involvement) and weight control in obese patients (to reduce pain related to weight bearing)
• complete immobilization should be avoided since it may cause hypercalcaemia (3)

Specific therapy

• bone turnover may be reduced with
  • bisphosphonates - these are now the mainstay of treatment (the bisphosphonates are more efficacious than previously used therapies such as calcitonin). Serum alkaline phosphatase levels or urinary hydroxyproline indicate the efficacy of the therapy; the latter falls more rapidly.
  • calcitonin - bisphosphonates have now replaced calcitonin as the medical treatment of choice for Paget's disease

Surgery:

• may be required for
  • pathological fracture - usually internal fixation when a long bone is affected
  • painful osteoarthritis - joint replacement
  • nerve entrapment or severe spinal stenosis - cord or nerve decompression

Reference:

• (1) Michou L, Brown JP. Emerging strategies and therapies for treatment of Paget's disease of bone. Drug Des Devel Ther. 2011;5:225-39.
• (2) Selby PL  et al. Guidelines on the management of Paget's disease of bone. Bone. 2002;31(3):366-73.
• (3) Whyte MP. Clinical practice. Paget's disease of bone. N Engl J Med.2006;355(6):593-600.