🔑 Key Learning

  • Elderly male (> 60) with unexplained bone pain and raised ALP
  • 1st line treatment is IV bisphosphonates (e.g. zoledronate)

🧬 Pathophysiology

  • Osteoclastic dysfunction causes excessive bone resorption
  • Dysregulated bone formation follows, leading to enlarged, deformed, and weakened bones

👀 Clinical Features

  • Usually > 50 years of age
  • Bone pain (most common symptom) — pelvis, spine, skull, femur
  • Fractures of affected bones
  • Hearing loss (skull involvement → compression of auditory nerve)
  • Frontal bossing (skull thickening) may be seen on examination

🧪 Investigations

  • ↑ ALP (isolated)
  • Normal calcium, phosphate, and PTH
  • X-rays: Enlarged, sclerotic, and deformed bones
  • Bone scan: Increased uptake in affected bones

💊 Management

  • 1st line: IV zoledronate (preferred bisphosphonate)
    • Alternative: Oral bisphosphonates if IV not tolerated

📝 Exam Clues & Clinchers

  • Elderly patient with bone pain and raised ALP, normal calcium → think Paget’s
  • 1st line treatment: IV bisphosphonates (zolendronate)