Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Neurological loss or pathological fracture
New limb weakness, sphincter dysfunction, cranial-nerve compromise, sudden deformity or inability to bear weight can reflect Pagetic spinal compression, skull-base complication or fracture through weak bone.
Action: Immobilise and image suspected fracture, perform urgent neurological assessment, and involve spinal, neurosurgical or orthopaedic teams immediately; biochemical treatment must not delay decompression or stabilisation.
Synopsis
Identify focal disordered bone remodelling, confirm suspected sites radiographically, map active involvement, distinguish Paget-related pain from adjacent osteoarthritis, and use symptom-directed bisphosphonate treatment while recognising neurological, fracture and malignant complications.
Paget disease is focal accelerated bone turnover producing enlarged, disorganised and mechanically weak bone; pelvis, spine, femur, tibia and skull are common sites.
Many cases are incidental after isolated raised ALP or characteristic radiography; confirm suspected sites with plain films and check total ALP with liver tests.
After radiographic diagnosis, radionuclide bone scintigraphy maps the full extent of metabolically active disease; uptake is sensitive but not specific.
Key red flags
Rapidly increasing focal bone pain, enlarging swelling, a soft-tissue mass or new destructive imaging requires urgent assessment for sarcomatous transformation or another malignancy.
Investigation priorities
01
First-line total ALP and liver testsFirst stepFirst line
Screen for increased bone turnover and distinguish a likely skeletal source from hepatobiliary ALP elevation.
Management branches
First-line diagnosisConfirm locally, map globally
Focal abnormal imaging, compatible pain or unexplained bone-source ALP elevation raises suspected Paget disease.
Take a site-specific history and examination, check total ALP with liver profile, calcium, phosphate, kidney function and vitamin D, and obtain targeted radiographs.
Once films are characteristic, arrange radionuclide scintigraphy to define distribution and image unexpected high-uptake sites anatomically when uncertain.
Preferred symptom treatmentSuppress painful active remodelling
Deep focal pain is attributable to active Paget disease and no urgent structural complication dominates.
Key medicines
Zoledronic acidGive 5 mg by intravenous infusion over at least 15 minutes as a single treatment, with adequate hydration, calcium and vitamin D; retreatment follows clinical relapse rather than a fixed calendar.
Risedronate sodiumTake 30 mg orally once daily for two months, at least 30 minutes before food, drink except water, or another medicine; remain upright for at least 30 minutes.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.