Page 75 - Retail Pharmacy Magazine October 2020

CPD ACTIVITY 73 Monitoring following remission Following remission, ALP should be tested every two years to detect relapse.1 Patients should also be monitored for recurrence of symptoms or progression of pagetic lesions. More frequent assessment should be done for patients who had severe disease at baseline (eg, ALP concentration above 600 units/lt) or patients with neurological symptoms.1 Relapse is more common and occurs earlier (most commonly within one to two years) following treatment with risedronate.1 Because of the risk of osteosarcoma, patients should be monitored indefinitely. Presentation of osteosarcoma is classically with increased bone pain that is poorly responsive to medical treatment, local swelling, and possibly a pathological fracture. Other therapies Calcitonin salmon (salcatonin). Calcitonin is a natural hormone which inhibits bone resorption. It was one of the first osteoclast inhibitors to be used in the treatment of Paget disease but is rarely used anymore because, although it improves bone pain and decreases total ALP concentration, results are short-lived and repeated injections are needed at frequent intervals. Long-term therapy has been associated with an increase in cancers.5 Denosumab. Two case reports of the use of denosumab 60mg by subcutaneous injection every six months in Paget disease patients for whom bisphosphonates were poorly tolerated or contraindicated showed a decrease in total ALP concentrations and an improvement in bone pain. However, there have been no clinical trials of denosumab in Paget disease and therefore, little evidence supporting its use.5 Surgery. Surgery is sometimes required to manage complications of advanced Paget disease. Joint replacement may be needed for secondary osteoarthritis, surgical decompression may be required for neurological syndromes associated with spinal Paget disease and oral maxillofacial surgery may be needed for cosmetic or dental deformities1. Supportive therapy. Physiotherapy promotes range of movement, muscular strength and ambulation skills. Exercise helps to maintain bone health and joint mobility, but as bones are weaker and more likely to fracture, certain forms of exercise are not suitable for people with Paget disease.4 Orthotics, walking sticks, crutches and walkers may be required as well as hearing aids for people with hearing deficits.4 Analgesics. The role of analgesics, as in all cases of chronic non-cancer pain, is as a part of a multimodal treatment plan. Current guidelines for analgesia for patients with chronic non- cancer pain note that opioid analgesia attenuates with time, while the likelihood of harm persists or increases over time.10 NSAIDs and paracetamol are widely used for pain control in patients with Paget disease and are needed for complications such as pain due to secondary osteoarthritis in a joint adjacent to Paget disease.2,4 Oral NSAIDs and COX-2 inhibitors are more effective than paracetamol for secondary osteoarthritis, but have a greater potential for harm, particularly in the older age group most commonly affected by Paget disease.11 Gastrointestinal toxicity can cause death and hospital admissions. The concomitant use of a proton pump inhibitor with NSAIDs may partially diminish gastrointestinal harm.12 The concomitant use of NSAIDs with risedronate may increase the risk of gastrointestinal adverse effects, although studies have not shown this to be the case.13,14 Cardiovascular and renal risks associated with these agents are JOIN TODAY TO ENJOY THESE MEMBER BENEFITS LEARN MORE www.acp.edu.au • CPD guarantee – four new topics each month • Learning plan and CPD credits summary transcript • Comprehensive and non-biased clinical education modules with online assessment questions TO PAGE 74 RETAIL PHARMACY • OCT 2020