Paget’s disease is a localized disorder of bone characterized by the disruption in normal bone remodeling. To understand the mechanism of development of Paget’s disease, one must know what exactly is bone remodeling. Bone remodeling in simpler terms can be called as bone metabolism. Our bone is an active tissue. New bones are constantly being formed, while old bones are continually being destroyed. Now, the question arises, what forms the bone and what destroys it? The bone-forming cells are known as Osteoblasts, and the bone-resorbing cells are known as Osteoclasts. In a healthy individual, the processes of bone formation and destruction are in harmony, thus maintaining a normal bone turnover.
In Paget’s disease, initially, there is overactivity of osteoclasts, which causes an increased bone destruction. This is followed by a compensatory overactivity of osteoblasts, leading to new bone formation. But, the matter of concern here is that the new bone formed is weaker, larger, has an increased blood supply and is more prone to fracture. All these anomalies in bone remodeling marks the development of Paget’s disease.
This disease is named after a surgeon, Sir James Paget, who first described the condition as a chronic inflammation of bone and called it, Osteitis deformans (Osteitis means swelling of bone and Deformans means deformity). Paget’s disease is usually asymptomatic, i.e., it does not present with any symptom in majority of cases. However, sometimes patients may present with minor complaints, most common being the bone pain.
As per recent statistical reports, 1 to 3 million people in the U.S. are affected by this condition. It is the second most common disease of the bone after osteoporosis. Commonly seen in men than women, Paget’s disease is broadly considered as a disease of the elderly. Besides, it may affect young individuals, known as Juvenile form of Paget’s disease. It is very different from the adult form of Paget’s disease.
The exact cause of this disease is still a subject of interest for the researchers. However, a strong genetic predisposition has been considered a major cause of the condition. Paget’s disease can be a debilitating condition for the patient as it increases the risk of bone fracture due to the brittle nature of the bone. If not recognized and treated at an early stage, it may progress to bone cancer, which can eventually cause death. However, the progression of the disease to bone cancer is rare. Hence, it is necessary that the general population is aware of the disease and appropriate interventions must be taken at an early stage.
Paget’s disease is a localized disease, which means, it is confined to a particular bone only, and does not spread. However, it may worsen the condition in the pre-existing site. It may affect a single bone or multiple bones at a time. Based on the number of bone(s) affected by Paget’s disease, it can be classified into 2 categories.
The bones affected by Paget’s disease in decreasing order of frequency are spine, femur (thigh bone), pelvis, skull, clavicle (collarbone) and the humerus (upper arm bone).
In most cases, Paget’s disease does not present with any symptom and is usually diagnosed incidentally during medical evaluation for some other condition. However, it may present with some symptoms in minority of cases. The most common symptom is bone pain. The clinical presentation depends on the bone involved, as described below:
Other symptoms seen in Paget’s disease are listed below:
If the Paget’s disease is not diagnosed and managed early, it may lead to severe complications. Some major complications of Paget’s disease are as follows:
There are various risk factors that may predispose an individual to Paget’s disease. These are as follows:
If an individual is a male in his 40s and has a family history of Paget’s disease, he is at the greatest risk of developing the disease too.
However, women, children and young adults may also be affected. A positive family history makes a person more susceptible to develop Paget’s disease regardless of his age, gender and nationality.
If an individual is experiencing dull bony pain or is developing a visible bone deformity in his/her skeleton, Paget’s disease may be the likely explanation. Bony pain along with visual impairment and hearing difficulties might be suggestive of Paget’s disease involving the skull.
However, if an individual had been experiencing dull bony pain, which has now worsened and can feel a soft tissue mass in the affected area, then it may may point toward bone cancer, which needs prompt treatment. Likewise, in case an individual has developed bone deformity, such as bowing of legs and is also experiencing pain in the respective joint, it is a strong indicator of Osteoarthritis occurring as a complication of Paget’s disease. Hence, it is always recommended to visit a doctor for proper diagnosis.
The exact cause of Paget’s disease is still a matter of active research. However, two main causative factors have been recognized in the development of Paget’s disease.
The disturbing fact is that Paget’s disease cannot be prevented. If an individual is at a high risk of developing the disease, he/she will develop it. However, preventive measures can be taken to arrest the disease at its earliest stage. Major preventive measures that one must keep in mind to prevent the complications of the disease are described below.
Paget’s disease is usually diagnosed when an individual is undergoing a medical evaluation. The reason being, its asymptomatic nature in the early stages. However, once a physician suspects Paget’s disease in a patient, several investigations are carried out that as listed below:
As this disease usually presents after 40 years of age, most patients ignore the bony pain thinking it a sign of normal aging. It is important for the individuals to realize that such symptoms along with a strong family history must seek medical help.
The features of Paget’s disease are sometimes confused with those of Osteoporosis. The difference between the two lies in their extent, i.e., Osteoporosis is a generalized condition, whereas Paget’s disease is a localized disease.
There is no cure for Paget’s disease. Hence, the goal of the treatment is to control the activity of the disease, relieve the symptoms and manage its complications. As already described, Paget’s disease affects many systems of the body, including bones, joints and even hearing ability. Thus, it’s treatment requires multi-disciplinary approach, i.e., a team of specialists collaborate to manage the condition effectively. Usually, an orthopedic surgeon (specialist of bone disorders), rheumatologist (specialist of musculoskeletal diseases and autoimmune disorders) and ENT specialist (specialist of Ear, Nose and Throat diseases) work together to manage the individual manifestations of the disease.
The treatment depends on the symptoms and the SAP levels. If a patient is asymptomatic with minimally elevated SAP, no treatment is required. However, if the disease is seen affecting major bones like skull or spine, treatment is necessary to prevent fatal complications. If a patient presents with symptoms and lab tests reveal marked elevation of SAP, treatment must be advocated. The various treatment modalities are as follows:
1. Medications:
Various drugs used in the treatment of Paget’s disease are discussed below:
A. Bisphosphonates: The mainstay of the treatment for Paget’s disease is the use of a drug, called Bisphosphonates. This class of drug suppresses the bone-destroying cells; hence, arresting the disease. These can be taken orally or through injections. The efficacy of bisphosphonate in the treatment is checked by the reduction in symptoms of the patient and reduction in SAP levels of the patient. The examples of bisphosphonates are enlisted below:
Oral drugs
Injectable Drugs
Although bisphosphonates are the most important drug in the treatment of Paget’s disease, it may produce some side effects in some patients such as degeneration of the jaw, musculoskeletal pain, flu-like symptoms, gastric irritation and reduced calcium level.
B. Salmon Calcitonin Therapy (Available as Miacalcin): In patients, who cannot tolerate bisphosphonate therapy, salmon calcitonin therapy is prescribed. Calcitonin is a hormone that inhibits the osteoclastic activity, and thus, reduces the bone destruction. It arrests the disease and prevents its progression. It is given either through injections or as a nasal spray. Injectable forms are given under skin or into the muscles. Nasal sprays are administered inside the nostrils.
However, calcitonin too causes some side effects in injectable as well as nasal spray form. vomiting, nausea, redness at the site of injection, skin rash and flushing are a few side effects of the calcitonin injection, while nose bleeding, runny nose (also, known as rhinorrhoea), headaches and bone pain.
C. Painkillers: Bone pain can be very disturbing for the patients of Paget’s disease. NSAIDs (non-steroidal anti-inflammatory drugs) or painkillers are prescribed by the doctor to relieve the pain.
2. Surgery
Surgical intervention for Paget’s disease is rarely needed. It is usually indicated in cases of unstable bone fracture and severe arthritis not responding to medications.
Because of the abnormal bone architecture and increased blood supply of the bone in Paget’s disease, the surgeon has to face many challenges during the procedure. The major challenge is increased tendency of bone bleeding during the surgery. To combat this, surgeons put the patients on medications a few months prior to the surgery. Medications reduce the severity of the condition to a considerable extent, which reduces the chance of bleeding during the surgery.
Various surgical procedures that may be required are as follows:
3. Rehabilitation
Daily activities can be cumbersome for a patient with Paget’s disease due to various reasons like bone fracture or extremely brittle bone susceptible to fracture, bone deformity affecting joint mobility and hearing loss. To curb these limitations, various rehabilitation measures are recommended by the doctor. These are described below:
Paget’s disease is usually diagnosed in the 50s of an individual. Sometimes, by the time it is diagnosed, it may have caused many debilitating complications. Arthritis, hearing loss and nerve compression can render a patient helpless and it may be difficult for him/her to lead daily life without assistance. Hence, it is important for the family members and peers to assist the patient and make the patient’s life easy.
Paget’s disease can affect the mental state of an individual by making him/her dependent on rehabilitating devices. Thus, the closed ones should motivate the patients to believe that the disease is manageable.
While bisphosphonates and calcitonin require prescription, some OTC pain-killers like acetaminophen, ibuprofen or naproxen can be taken to relieve the pain caused by the disease.
Moreover, bisphosphonates and calcitonin cause a reduction in blood calcium level. Hence, doctor usually prescribes a calcium and vitamin D supplement along with these medications. These supplements are available over the counter. However, it must be noted that calcium reduces the absorption of bisphosphonates, and so, reduces its efficacy. Thus, patients are advised to maintain a gap of at least 2 hours between the intake of bisphosphonates and calcium supplements.
Other than medical intervention, self-management plays a vital role in managing Paget’s disease. Various ways to self-manage the disease are as follows:
As already mentioned, Paget’s disease cannot be prevented. However, there are some natural ways to manage it:
Health experts suggest that every individual must realize that Paget’s disease is an unavoidable bone disorder. However, recognizing it at an early stage can prevent its complications. Arresting the disease at an early stage can significantly improve the quality of life of an individual. Hence, be informed of your family history. If suspecting the disease, seek medical help immediately. Once diagnosed, strictly adhere to the drug regime. Follow a healthy diet and stay active.
Academician, Shelly's rich experience as an academic and research professional speaks volume. Her fields of interest are genetics, biotechnology and drug research. Shelly keeps herself abreast with latest scientific researches all around the globe and loves to write about the same.
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