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Paget Disease of Bone

(Paget's Disease of Bone; Osteitis Deformans)


Julia F. Charles

, MD, PhD, Harvard Medical School

Last full review/revision Apr 2021| Content last modified Apr 2021
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Paget disease of bone is a chronic disorder of the adult skeleton in which bone turnover is accelerated in localized areas. Normal matrix is replaced with softened and enlarged bone. The disease may be asymptomatic or cause gradual onset of bone pain or deformity. Diagnosis is by x-ray. Treatment includes symptomatic measures and often drugs, usually bisphosphonates.

About 1% of adults > 40 in the US have Paget disease, with a 3:2 male predominance. Prevalence increases with age. However, overall prevalence seems to be decreasing. The disease is most common in Europe (except Scandinavia), Australia, and New Zealand.

General references

  • 1. Ralston SH, Corral-Gudino L, Cooper C, et al: Diagnosis and management of Paget's disease of bone in adults: a clinical guideline. J Bone Miner Res 34(4):579-604, 2019. doi: 10.1002/jbmr.3657. Epub 2019 Feb 25. PMID: 30803025; PMCID: PMC6522384.

  • 2. Reid IR: Recent advances in understanding and managing Paget's disease. F1000Res. 2019;8:F1000 Faculty Rev-1485. Published 2019 Aug 22. doi:10.12688/f1000research.19676.1

  • 3. Singer FR, Bone HG 3rd, Hosking DJ, et al: Paget's disease of bone: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 99(12):4408-22, 2014. doi: 10.1210/jc.2014-2910. PMID: 25406796.

Etiology of Paget Disease of Bone

About 10% of patients with Paget disease have mutations of the SQSTM1 (sequestosome-1) gene, resulting in increased nuclear factor kappa-B activity, which increases osteoclast activity (1, 2). Several other mutations associated with Paget disease have been identified, many affecting the RANK (receptor activator of nuclear factor kappa-B) signaling pathway that is critical for osteoclast generation and activity. A viral etiology, such as measles, has been proposed because nuclear inclusions in diseased osteoclasts that are similar to those seen in paramyxovirus-infected cells have been seen on electron microscopy. Although a viral cause has not been established, it is hypothesized that in genetically predisposed patients an as yet unidentified virus triggers abnormal osteoclast activity.

Etiology reference

  • 1. Laurin N, Brown JP, Morissette J, Raymond V: Recurrent mutation of the gene encoding sequestosome 1 (SQSTM1/p62) in Paget disease of bone. Am J Hum Genet 70:1582–1588, 2002. doi: 10.1086/340731

  • 2. Rea SL, Walsh JP, Layfield R, et al: New insights into the role of sequestosome 1/p62 mutant proteins in the pathogenesis of Paget's disease of bone. Endocr Rev 34(4):501-24, 2013. doi: 10.1210/er.2012-1034. Epub 2013 Apr 23. PMID: 23612225.

Pathophysiology of Paget Disease of Bone

Any bone can be involved in Paget disease. The bones most commonly affected are the pelvis, femur, and skull. Other less commonly involved bones are the tibia, vertebrae, clavicle, and humerus.

Bone turnover is accelerated at involved sites. Pagetic lesions are metabolically active and highly vascular. Excessively active osteoclasts are often large and contain many nuclei. Osteoblastic repair is also hyperactive, causing coarsely woven, thickened lamellae and trabeculae. This abnormal structure weakens the bone, despite bone enlargement and areas of bone sclerosis.


The most common complication of Paget disease of bone is

Osteoarthritis occurs in up to 50% of patients and develops in joints adjacent to involved bone. Pathologic fracture is also common due to focal areas of weakened bone.

Overgrown bone may compress nerves and other structures passing through small foramina. Spinal stenosis or spinal cord compression may develop.

Rare complications include transformation to osteosarcoma in < 1% of patients. Highly vascular bones may bleed excessively during orthopedic surgery. Very rarely, hypercalcemia develops in patients who are immobile; however, hypercalcemia in ambulatory patients suggests the coexistence of hyperparathyroidism. High-output heart failure due to large or numerous lesions has been reported.

Symptoms and Signs of Paget Disease of Bone

Paget disease of the bone is usually asymptomatic. If symptoms occur, they develop insidiously, with pain, stiffness, fatigue, and bone deformity. Bone pain is aching, deep, and occasionally severe, sometimes worse at night. Pain also may arise from compression neuropathy or osteoarthritis. If the skull is involved, there may be headaches and hearing impairment.

Signs may include skull enlargement bitemporally and frontally (frontal bossing), dilated scalp veins, and nerve deafness in one or both ears. Symptoms may include vertigo and headaches. Deformities may develop from bowing of the long bones or osteoarthritis. Pathologic fractures may be the presenting manifestation. Osteosarcoma is often suggested by increasingly severe pain.

Diagnosis of Paget Disease of Bone

  • Plain x-rays

  • Serum alkaline phosphatase, calcium, and phosphate

  • Bone scan to establish the extent and location of disease

Paget disease should be suspected in patients with the following:

  • Unexplained bone pain or deformity

  • Suggestive findings on x-ray

  • Unexplained elevation of serum alkaline phosphatase on laboratory tests done for other reasons, particularly if gamma-glutamyl-transpeptidase (GGT) is normal

  • Hypercalcemia that develops during bed rest, particularly among older patients

  • Bone sarcoma in older patients

If Paget disease is suspected, plain x-rays and serum alkaline phosphatase, calcium, and phosphate levels should be obtained. Confirmation on x-ray is required to establish the diagnosis. Characteristic x-ray findings include the following:

  • Increased bone sclerosis

  • Abnormal architecture with coarse cortical trabeculation or cortical thickening

  • Bowing

  • Bone enlargement

There may be lateral stress microfractures of the tibia or femur. However, if x-ray findings are not definitive for Paget disease and there is diagnostic uncertainty, biopsy should be considered to exclude bony metastatic disease.

Radionuclide bone scan using technetium-labeled phosphonates should be done at baseline to determine the extent of bone involvement.

Characteristic laboratory findings include elevated serum alkaline phosphatase (increased anabolic activity of bone) but usually normal gamma-glutamyl-transpeptidase (GGT) and serum phosphate levels. Serum calcium is usually normal but can increase because of immobilization or hyperparathyroidism. If alkaline phosphatase is not elevated or it is unclear whether the increased serum alkaline phosphatase is of bony origin (ie, if GGT is increased in proportion to alkaline phosphatase), a bone-specific fraction can be measured. Serum markers of bone turnover, such as procollagen type I intact N-terminal propeptide (PINP) and C-telopeptide cross-links (CTX), may be elevated.

Pearls & Pitfalls

  • Consider Paget disease of bone in older adults with elevated alkaline phosphatase but normal GGT levels.

Treatment of Paget Disease of Bone

  • Supportive care for symptoms and complications

  • Bisphosphonates if disease is symptomatic or active in bones at risk of complications

Supportive treatment of Paget disease of bone includes analgesics or nonsteroidal anti-inflammatory drugs (NSAIDs) for pain. Orthotics help correct abnormal gait caused by bowed lower extremities. Some patients require orthopedic surgery (eg, hip or knee replacement, decompression of the spinal cord). Weight bearing should be encouraged, and bed rest should be avoided.

Localized, asymptomatic disease may not require treatment.

Drug therapy

Drug therapy suppresses osteoclast activity. It is indicated for the following:

  • To prevent or retard progression of complications (eg, hearing loss, deformity, osteoarthritis, paraparesis or paraplegia related to vertebral Paget disease, or other neurologic deficits, particularly in a poor surgical candidate)

  • To treat pain clearly related to the pagetic process and not to another source (eg, osteoarthritis)

  • To prevent or minimize bleeding that can occur during orthopedic surgery

  • To suppress excessive osteoclast activity when serum alkaline phosphatase (of bony origin) is > 2 times the normal level, even in the absence of symptoms

Although disease progression can be retarded, existing deficits (eg, deformity, osteoarthritis, hearing loss, neural impingement) are not reversed.

Several bisphosphonates are available and are the drugs of choice (see table Drug Therapy for Paget Disease). The amino-bisphosphonates (bisphosphonates with an extra nitrogen atom), particularly zoledronic acid, more effectively suppress markers of disease activity and provide more prolonged response (1). Zoledronic acid is recommended as first-line therapy for Paget disease of bone in professional guidelines, whereas other amino-bisphosphonates (such as alendronate, risedronate, and pamidronate) are 2nd-line and the simple bisphosphonates (bisphosphonates without an extra nitrogen atom, such as tiludronate and etidronate) are 3rd-line therapy.

Synthetic salmon calcitonin is an alternative to bisphosphonates for patients intolerant of or resistant to them. For patients with contraindications to bisphosphonates, case reports suggest that denosumab may also be an alternative to bisphosphonates (2).

Because bone turnover is increased, patients should ensure adequate intake of calcium and vitamin D, and supplements are often needed.


Drug Therapy for Paget Disease




First-line therapies

Zoledronic acid*

5 mg IV given as a single 15-minute infusion

A single dose is effective in most patients.

Hypocalcemia can develop if the 25OH vitamin D level is insufficient.

Second-line therapies


40 mg orally once/day for 6 months

This drug is taken as a single dose after rising in the morning, at least 30 minutes before eating.


30 mg orally once/day for 2 months

This drug is taken the same way as alendronate.


30 mg IV once/day given as a 4-hour infusion for 3 consecutive days or 90 mg IV given once

Possibly more frequent doses are needed in patients with resistant disease.

May repeat if clinically indicated.

Third-line therapies


5–10 mg/kg orally once/day for 6 months; higher doses (11–20 mg/kg orally once/day for 3 months) possibly needed in markedly active disease

This drug is taken as a single dose on an empty stomach at least 2 hours before or after eating; can be repeated after a 3- to 6-month interim if needed.

This drug is a 2nd-line therapy due to impaired mineralization.


400 mg orally once/day for 3 months

This drug is taken as a single dose after rising in the morning, at least 30 minutes before eating.

Alternative therapies

Synthetic salmon calcitonin

50–100 units (0.25–0.5 mL) subcutaneously or IM once/day

The dose is sometimes tapered to 50 units every other day and perhaps to twice or once weekly after a favorable initial response (often after 1 month).

This drug is indicated for patients who cannot tolerate bisphosphonates.

* Indicates an amino-bisphosphonate (a bisphosphonate with an extra nitrogen atom).

† This drug is not available in the US.

Treatment references

  • 1. Reid IR, Lyles K, Su G, et al: A single infusion of zoledronic acid produces sustained remissions in Paget disease: Data to 6.5 years. J Bone Miner Res 26(9):2261–2270, 2011. doi: 10.1002/jbmr.438

  • 2. Reid IR, Sharma S, Kalluru R, Eagleton C: Treatment of Paget's disease of bone with denosumab: Case report and literature review. Calcif Tissue Int 99(3):322–325, 2016. doi: 10.1007/s00223-016-0150-6

Key Points

  • Paget disease of bone is a common and often asymptomatic abnormality, particularly among older adults.

  • Complications can include osteoarthritis, fractures, neural compression, osteosarcoma, and rarely hypercalcemia.

  • Complications of bisphosphonate treatment of Paget disease of bone include hyperparathyroidism and hypocalcemia.

  • Confirmation is usually by x-rays showing findings such as bone sclerosis, coarse cortical trabeculation or cortical thickening, and bone bowing or enlargement.

  • First-line treatment is zoledronic acid.

Drugs Mentioned In This Article

Drug Name Select Trade
No US brand name
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