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Paget disease of bone — SCE Rheumatology MCQ

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HardMetabolic bone diseasePaget disease of boneSCE Rheumatology

A patient with established Paget disease previously received zoledronate. They are pain-free and functionally stable, but alkaline phosphatase has drifted to 1.4 times ULN. Imaging shows no new complication. What is the best strategy?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: A — Clinical surveillance without retreatment for the isolated biochemical rise

Explanation lettering: D = shown as A · E = shown as B · A = shown as C · C = shown as D · B = shown as E

D is correct. The UK-led Paget guideline favours symptom improvement over a treat-to-target strategy aimed only at normalising ALP. Retreatment is justified by active clinically relevant disease, especially Pagetic bone pain, not a modest isolated biochemical rise. Calcitonin cycling, rotating bisphosphonates and prophylactic arthroplasty add harm without evidence of better clinical outcomes.

Reference: UK-led clinical guideline for Paget disease of bone. https://academic.oup.com/jbmr/article/34/4/579/7606010