what-when-how
In Depth Tutorials and Information
Bisphosphonates, which inhibit osteoclastic bone
resorption, have been most frequently used in the
treatment of transient osteoporosis. In the reported
cases relief of pain is observed over a period of several
weeks (4-12 weeks) as contrasted to the several months
required to achieve pain relief with conservative treat-
ment. However, as illustrated in
Table 39.2
there is wide
variation in both doses administered and the treatment
schedules. Both oral and intravenous agents appear to
be successful. Furthermore, it is cautioned that the cases
reported are the successes; the nonresponders are not
reported.
X-rays revealed osteopenia without joint space nar-
rowing or destruction. MRI showed the characteristic
findings of TMO. One month after delivery the patient
was treated with neridronate sodium, 25 mg intramus-
cular/month, calcium carbonate and cholecalciferol.
After 3 weeks, including bed rest, the patient reported
improvement and after 2 months she was asymptom-
atic. MRI was normal after 4 months of therapy.
These selected cases suggest that antiresorptive
treatment with calcitonin or bisphosphonate treat-
ment may shorten the duration of symptoms in TMO.
However, with regard to OI, experience with the treat-
ment responses in terms of bone density and fracture
incidence to bisphosphonates and calcitonin in chil-
dren and adults with OI suggests that the response with
TMO may be more variable in the OI population.
Bisphosphonates and Transient Osteoporosis
In 2003 Schapira reported on a 30-year-old woman
with pain in her left hip area and inability to walk. Left
inguinal pain with irradiation to the upper thigh and
knee, progressive limitation of motion and sensation of
locking of the hip joint had appeared three and a half
months earlier, at the end of the sixth month of her first
pregnancy.
30
Two weeks after delivery she could not
walk because of pain and was admitted to hospital.
Biochemical tests were normal, X-rays showed severe
osteopenia in the left hip. DEXA revealed advanced
osteoporosis. She was treated with intravenous clon-
ronate (300 mg/d × 10 d) with calcium and vitamin D
supplements. After 2 weeks the pain was significantly
reduced and the patient could walk with only a slight
limp. Two months later she was completely asymptom-
atic with an increase in DEXA bone mineral density.
A second course of IV clodronate (5 days) was started to
reduce fracture risk. Two months later there was more
of an increase in bone mineral density.
Varenna, treating 16 patients, showed that pamidro-
nate, 45 mg, intravenously administered three times,
once every third day for 3 days, was effective in reliev-
ing pain and produced normal MRI results. Patients
recovered clinically after 1 month and MRI findings
normalized after 4 months.
7
Transient osteoporosis developed in the navicular
bone of a 20-year-old female track athlete. Standard
X-rays were normal. The patient received conserva-
tive treatment with limited weight bearing. However,
pain continued for 6 weeks. Alendronate 70 mg once
a week for 12 weeks was started. Symptom reduction
occurred after 2 weeks and MRI follow-up after 12
weeks revealed complete resolution of bone marrow
edema.
12
La Montagna reported on a case of TMO in a
36-year-old woman with a history of fibromyalgia who
developed pain in her bilateral upper thighs in the last
weeks of her pregnancy.
31
After delivery, her pain con-
tinued and she had difficulty walking. After 4 weeks
Calcitonin
Arayssi
3
treated two women with calcitonin, one
during pregnancy and one postpartum. Both experi-
enced symptom resolution in 6-9 weeks. Another case
reported a 42-year-old at woman 37 weeks' gestation +
TMO/MRI, treated with calcitonin nasal spray, calcium,
vitamin D and protected weight bearing. She experi-
enced 70% improvement in signs and symptoms after
3 weeks. After 6 weeks there was complete symptom
resolution. MRI 12 months later was normal.
Trevisan reports on three middle-aged men who
experienced at least four episodes of transient migra-
tory osteoporosis. Antiresorptive treatment with either
alendronate, calcitonin or clodronate reduced the sever-
ity of pain time and the duration of disability from epi-
sode to episode in all three men.
16
Anabolic Agent
A 62-year-old male presented a 2-month history of
left hip pain. Although pelvic X-rays were negative,
MRI showed bone marrow edema of the left femur.
Teriparatide treatment was instituted at a dose of 20 μg/
day subcutaneously. Symptoms cleared by 4 weeks
with normalization of the MRI after 1 month.
29
Prostacyclin Analog
Iloprost is a prostacyclin analog that inhibits plate-
let and leucocyte activation, counteracts vasospasm,
induces vasodilatation in arteries and veins, and protects
the endothelium.
32
Forty-one patients with painful isch-
emic or mechanical bone edema (BME) of the knee were
enrolled in a double-blind, randomized controlled study
testing oral iloprost (group 1) vs. tramadol (group 2).
Thirty-three completed the study. The treatment duration
