Consensus statement on the modern therapy of Paget's disease of bone from a western osteoporosis alliance symposium

Background: Bisphosphonate therapy remains the most effective way of controlling Paget's disease of bone (PD). Along with salmon calcitonin, etidronate has been the mainstay of therapy for similar to 20 years. However, the advent of newer bisphosphonates with different molecular actions on osteoclasts warrants a reevaluation of optimal treatment. Objective: At a symposium of the Western Osteoporosis Alliance, physicians with experience in the management of PD met to review currently available information and generate this consensus statement as a guideline for clinicians and a source of information for health care payers. Methods: All available randomized, double-blind, controlled studies that compared the efficacy of newer bisphosphonates with that of etidronate in the treatment of PD were identified through a search of MEDLINE (R) using the terms Paget's disease, bisphosphonates, pamidronate, etidronate, alendronate, risedronate, tiludronate, clodronate, calcitonin, and salmon calcitonin. Because no such studies have been conducted for pamidronate, clodronate, or calcitonin. these drugs were not included in the analysis. Conclusions: The consensus of the symposium was that etidronate has little place in the modern management of PD. Newer bisphosphonates such as alendronate and risedronate provide significant therapeutic advantages over etidronate, both in the extent of reduction in bone-specific alkaline phosphatase (BSAP) and/or total serum alkaline phosphatase (SAP) and in the duration of remission, as measured by normalization of BSAP/SAP. In the absence of a direct comparison between alendronate and risedronate in the treatment of PD, physician choice is likely to be based on personal experience, relative cost, and differences in dosing.