CASE 3 PAGET’S DISEASE OF BONE

A 55 year old Caucasian male comes to your office complaining of deep, aching pain in the right tibia and lumbar spine for six months as well as bifrontal headaches for two years. Vital signs were normal. There was a one-half inch increase in hat size and minimal bifrontal enlargement. His right leg was 1/2 inch short and there was 15% lateral bowing and increased warmth in the tibia. The lumbar area was normal to exam. His father had a history of Paget's disease of bone.

His chemistry group was normal except for a four-fold increase of alkaline phosphatase. Bone scan showed increased incorporation of isotope in the head, third lumbar vertebra and the right tibia. Plain radiographs showed: an enlarged Pagetic skull with marked osteoblastic changes; increased cortical and trabecular thickening of the third lumbar vertebra; and lateral bowing and cortical thickening with fissure fractures along the convex surface of the right tibia.

You treated the patient with alendronate, 40 mg p.o. daily which caused elimination of the headaches, lumbar and tibia pain as well as normalization of the alkaline phosphatase in 6 months. During the first month of this treatment he developed perioral numbness and finger tingling which improved when he received eight 650 mg tablets of calcium carbonate in divided doses each day.

2. List some major complications of Paget’s disease of bone.

3. What are the major reasons Paget’s disease of bone is treated? 

4. What are the advantages of alendronate as compared to calcitonin and etidronate for the treatment of Paget's disease?

5. Discuss prevention of major side effects caused by alendronate.