A 73-year-old man comes to the office due to pain and restriction of movement in his left hip joint for the last 6 months. He has been taking over-the-counter acetaminophen 2-3 times a day, although this does not give any significant relief from this pain. His medical history is significant for type 2 diabetes mellitus 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 20s. Currently, he drinks a glass of wine over the weekends. 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. A basic metabolic profile, including calcium and creatinine levels, is unremarkable. What is the most appropriate treatment for this patient?

Question

A 73-year-old man comes to the office due to pain and restriction of movement in his left hip joint for the last 6 months.  He has been taking over-the-counter acetaminophen 2-3 times a day, although this does not give any significant relief from this pain.  His medical history is significant for type 2 diabetes mellitus 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 20s.  Currently, he drinks a glass of wine over the weekends.  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.  A basic metabolic profile, including calcium and creatinine levels, is unremarkable.  What is the most appropriate treatment for this patient?

Quizplus · Accepted Answer

Explanation: This patient most likely has Paget disease of bone (osteoclast abnormalities leading to increased bone turnover and abnormal remodeling), as evidenced by his symptoms (eg, bony pain), x-ray features (eg, thickened cortex, sclerotic lesions), and bone scan findings (eg, increased uptake due to increase bone remodeling). Laboratory studies include normal calcium and, often, elevated alkaline phosphatase levels. The involvement of his left proximal femur, which is a weight-bearing bone, warrants treatment with an oral bisphosphonate such as alendronate. Treatment of Paget disease is indicated when patients have symptomatic disease, including intolerable pain, involvement of weight-bearing bones, or neurological involvement; other indications for treatment, which develop more rarely, include hypercalcemia (usually due to immobilization as a result of widespread bony lesions, not due to Paget disease itself), hypercalciuria, and congestive heart failure. Several bisphosphonates (eg, zoledronic acid, alendronate, risedronate) are approved for the treatment of Paget disease due to their antiresorptive properties. For patients who cannot tolerate bisphosphonates, calcitonin (a less potent antiresorptive agent) can be considered. (Choice B)Calcitriol (1,25-dihydroxyvitamin D), an active metabolite of vitamin D, is indicated for treatment of renal osteodystrophy and hypoparathyroidism. This patient has normal renal function and normal calcium levels. Calcitriol will not be helpful in this patient. (Choice C)Radiotherapy could be used for metastatic bone lesions. This patient's x-ray features are not consistent with metastatic bone disease, which is usually characterized by punched out lesions that are sometimes accompanied by surrounding sclerosis. Metastatic prostate cancer can cause sclerotic lesions, but the increased uptake in the frontal bone and the lack of an enlarged prostate (normal physical examination) make prostate cancer less likely. (Choice D)Ibuprofen can be used to control pain in patients with Paget disease; however, it will not lead to long-lasting remission. Ibuprofen can be used in this patient until the effect of alendronate begins. One should be cautious in using nonsteroidal anti-inflammatory drugs in elderly patients because of the danger of increased toxicity, particularly renal failure. (Choice E)Prednisone is not indicated in treatment of Paget disease. Educational objective: Indications for treatment of Paget disease include bone pain, involvement of weightbearing bones, and neurological compromise. Bisphosphonates are the preferred therapy for the treatment of Paget disease.

A 73-Year-Old Man Comes to the Office Due to Pain