Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

asymptomatic patients, incidental diagnosis

1st line – observation, regular follow-up, patient education, preventive measures

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ONGOING
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asymptomatic patients, incidental diagnosis
1st line – 

observation, regular follow-up, patient education, preventive measures

These patients are observed but do not usually require pharmacological therapy as long as they remain asymptomatic.

Plus – bisphosphonate or calcitonin

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asymptomatic patients, incidental diagnosis
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active disease in an area considered high risk for complications
Plus – 

bisphosphonate or calcitonin

Treatment recommended for ALL patients in selected patient group

Bisphosphonates are potent inhibitors of bone resorption and are the mainstay of treatment for PDB.

Consider bisphosphonates as first-line drug treatment.[28] Zoledronic acid, alendronic acid, and risedronate sodium are used as first-line agents. [ Cochrane Clinical Answers logo ] [ Cochrane Clinical Answers logo ] A Cochrane review found moderate-quality evidence that bisphosphonates improved pain in people with PDB when compared with placebo.[41]

Calcitonin is generally indicated only in people who are unable to tolerate bisphosphonates, or in whom bisphosphonates are contraindicated. Use of a bisphosphonate and calcitonin together is contraindicated.

Calcium and vitamin D levels should be normal before bisphosphonate treatment to reduce the risk of hypocalcaemia or worsening osteomalacia.[3]

Primary options

zoledronic acid: 5 mg intravenously as a single dose

OR

alendronic acid: 40 mg orally once daily for 6 months

OR

risedronate sodium: 30 mg orally once daily for 2 months

Secondary options

calcitonin-salmon: 100 units subcutaneously/intramuscularly once daily on day 1, followed by 50-100 units every 1-3 days as tolerated

symptomatic patients

1st line – bisphosphonate or calcitonin

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ONGOING
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symptomatic patients
1st line – 

bisphosphonate or calcitonin

Bisphosphonates are recommended as a first-line drug treatment for patients with symptomatic PDB.[28]

Zoledronic acid, alendronic acid, and risedronate sodium are used as first-line agents. [ Cochrane Clinical Answers logo ] [ Cochrane Clinical Answers logo ] A Cochrane review found moderate-quality evidence that bisphosphonates improved pain in people with PDB when compared with placebo.[41]

Calcitonin is generally indicated only in people who are unable to tolerate bisphosphonates, or in whom bisphosphonates are contraindicated. Use of a bisphosphonate and calcitonin together is contraindicated.

Calcium and vitamin D levels should be normal before bisphosphonate treatment to reduce the risk of hypocalcaemia or worsening osteomalacia.[3]

Primary options

zoledronic acid: 5 mg intravenously as a single dose

OR

alendronic acid: 40 mg orally once daily for 6 months

OR

risedronate sodium: 30 mg orally once daily for 2 months

Secondary options

calcitonin-salmon: 100 units subcutaneously/intramuscularly once daily on day 1, followed by 50-100 units every 1-3 days as tolerated

Plus – supportive therapies

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symptomatic patients
Plus – 

supportive therapies

Treatment recommended for ALL patients in selected patient group

Physiotherapy provides an opportunity for education about high-risk activities, and promotes range of motion, muscular strength, and ambulation skills. If long-bone deformity ensues, orthoses can be added to the therapy, as well as training using walking aids such as walking sticks, crutches, and walkers.

The use of hearing aids is recommended at a very early stage for people with hearing deficits because of the progressive nature of the disease.

Analgesics are indicated for pain and inflammatory symptoms.

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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