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Paget Disease — SCE Rheumatology MCQ

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ModerateMetabolic Bone DiseasePaget DiseaseSCE Rheumatology

A 45-year-old man has persistent deep lumbar pain that is clinically localised to vertebrae affected by radiographically confirmed Paget disease of bone. Alternative causes of his pain, including degenerative spinal disease and vertebral fracture, have been excluded. His serum total alkaline phosphatase is 650 U/L (reference range <130), with otherwise normal liver tests. Serum calcium and 25-hydroxyvitamin D are normal, and his creatinine clearance is 80 mL/min. What is the most appropriate disease-specific treatment?

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Correct answer: B — Intravenous zoledronic acid

The correct answer is **B, intravenous zoledronic acid**. His pain is attributable to metabolically active Paget disease, so disease-specific treatment is indicated. Current Paget disease guidance recommends bisphosphonates for pagetic bone pain and identifies zoledronic acid as the bisphosphonate most likely to provide a favourable pain response. The usual regimen is a single 5 mg intravenous infusion, provided hypocalcaemia and severe renal impairment have been excluded and calcium/vitamin D status is adequate. Oral risedronate and alendronate can suppress disease activity but are less effective and less durable alternatives when zoledronic acid is unsuitable. Observation is inappropriate because he has pagetic bone pain; an elevated alkaline phosphatase alone would not necessarily mandate treatment. Calcitonin is less effective and is not standard first-line therapy.

Reference: Ralston SH et al. Diagnosis and Management of Paget's Disease of Bone in Adults: A Clinical Guideline. Journal of Bone and Mineral Research. 2019;34:579–604. https://pubmed.ncbi.nlm.nih.gov/30803025/