Paget’s disease of bone: an often overlooked metabolic bone condition

What is Paget’s disease?

Paget’s disease of bone is a condition in which the normal cycle of bone breakdown and rebuilding becomes dysregulated, producing abnormal bone that is larger, denser in appearance, but structurally weaker than normal. It most commonly affects the pelvis, spine, skull, and long bones of the legs. It is significantly more common than most people realise — affecting approximately 1 in 20 adults over 55 in the UK — and is frequently diagnosed incidentally or after years of symptoms attributed to other causes.

Who gets it?

• Predominantly affects adults over 55; more common in men than women
• Strong genetic component — family history increases risk substantially
• More common in the UK, Australia, and New Zealand than in Asia or Africa
• Often asymptomatic — discovered incidentally on X-ray or when alkaline phosphatase is found elevated on a blood test

How Paget’s causes back pain

Diagnosis and treatment

Alkaline phosphatase (ALP) is typically markedly elevated in active Paget’s disease and is a useful screening test. A bone scan identifies the distribution of active disease across the skeleton. X-rays show a characteristic coarsened trabecular pattern in affected bones.

Bisphosphonate therapy — either a single intravenous infusion of zoledronic acid or oral alendronate — effectively suppresses Pagetic activity in most patients. A single infusion of zoledronic acid produces remission in over 90% of patients for several years. Treatment is straightforward and highly effective when the diagnosis is made.

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