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Indications for Bisphosphonate Treatment


Paget Disease: When to Treat and When Not to Treat

  • Authors: Frederick R. Singer, MD
  • CME Released: 8/4/2009
  • Valid for credit through: 8/4/2010, 11:59 PM EST
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Target Audience and Goal Statement

This activity is intended for primary care physicians, orthopaedists, endocrinologists, rheumatologists, and other physicians who care for patients with Paget's disease.

The goal of this activity is to diagnose and treat Paget's disease effectively.

Upon completion of this activity, participants will be able to:

  • Identify elements of the clinical presentation of Paget's disease
  • Describe complications of Paget's disease
  • Specify the most potent bisphosphonate in the treatment of Paget's disease
  • Classify who should receive immediate treatment for Paget's disease


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  • Frederick R. Singer, MD

    Director, Endocrine/Bone Disease Program, John Wayne Cancer Institute, Saint John's Health Center, Santa Monica, California; Clinical Professor of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, California


    Disclosure: Frederick R. Singer, MD, has disclosed that he has acted as a consultant for Amgen Inc. Dr. Singer has also disclosed that he has acted as a consultant to, been involved in speaker's bureaus for (honoraria), and has received grant/research support (including for clinical trials) from Merck & Co., Inc.; Novartis Pharmaceuticals Corporation; and Procter & Gamble.

CME Author(s)

  • Charles P. Vega, MD, FAAFP

    Associate Professor; Residency Director, Department of Family Medicine, University of California, Irvine


    Disclosure: Charles P. Vega, MD, FAAFP, has disclosed no relevant financial relationships.


  • Jenny Buckland

    Editor, Nature Reviews Rheumatology


    Disclosure: Jenny Buckland has disclosed no relevant financial relationships.

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Paget Disease: When to Treat and When Not to Treat

Authors: Frederick R. Singer, MDFaculty and Disclosures

CME Released: 8/4/2009

Valid for credit through: 8/4/2010, 11:59 PM EST


Abstract and Introduction


Paget disease of bone is a focal disorder of the skeleton that can affect one or more bones. Many patients are discovered accidentally because of elevated serum alkaline phosphatase activity or an abnormal skeletal radiograph intended to evaluate an unrelated condition. Patients are often asymptomatic, but a subset experience considerable morbidity that can include bone pain and skeletal deformity, as well as a variety of regional complications, such as hearing loss associated with cranial involvement, degenerative arthritis of the hip or knee, fractures of the lower extremities and, rarely, sarcoma or giant cell tumors. Bisphosphonates have proven to be effective in controlling disease activity because they inhibit osteoclast function. Administration of these agents can relieve bone pain, decrease biochemical markers of bone resorption and bone formation, and retard or reverse the early osteolytic phase of the disease. Future studies are needed to determine whether these drugs, if used in an early stage of the disease, can prevent complications in asymptomatic patients.


In 1877 sir James Paget published his classic study of patients he had seen with focal enlargement and de formity of the skeleton.[1] Later, with the advent of radiologic evaluation of the skeleton,[2] it was appreciated that the earliest phase of Paget disease was characterized by one or more focal osteolytic lesions, which developed over many years into sclerotic lesions that could then be detected on physical examination (Figure 1).

Figure 1.


Cortical changes in an untreated patient with Paget disease. Evolution of cortical changes in the left tibia on the lateral view of an untreated woman with Paget disease from age 45 to 68 years, as assessed by radiography. The arrows indicate the area of marked cortical thickening. The distal tibia appeared normal in 1964, but sclerotic changes progressively increased by 1987. Anterior bowing, which was mild in 1964, became progressively worse by 1987. Reproduced with permission from the American society for Bone and Mineral research © J. Bone Miner. Res. 12, 691–692 (1997).