Pamidronate Effective, Well-Tolerated for Chronic Nonbacterial Osteitis in Children

MRI of a knee joint showing the destruction of bone due to advanced osteomyelitis
MRI of a knee joint showing the destruction of bone due to advanced osteomyelitis
Using whole-body MRI, this study evaluates the efficacy of pamidronate in children with chronic nonbacterial osteitis.

Study data results published in Pediatric Rheumatology support the efficacy and tolerability of pamidronate for chronic nonbacterial osteitis (CNO) in children.

Investigators conducted a retrospective medical record review of children diagnosed with CNO between 2005 and 2018 at a tertiary health center in the United Kingdom. Children with disease onset before the age of 16 years who received bisphosphonates were included in the study. Pre and posttreatment whole-body magnetic resonance imaging (WB-MRI) data were extracted; treatment response was ascertained based on WB-MRI lesion status. Patient exposure to nonsteroidal anti-inflammatory drugs (NSAIDs), methotrexate, and corticosteroids was also extracted.

The final study cohort comprised 46 patients with a mean follow-up duration of 6 years (range, 1-13 years). Prior to treatment with pamidronate, 35 patients had a trial of NSAIDs, 4 received corticosteroids, and 5 had a trial of methotrexate. Patients with poor clinical or radiologic response to initial treatment were escalated to pamidronate. However, bisphosphonates were used as first-line treatment in 9 patients (19.5%) with spinal lesions and 2 patients (4.3%) with mandibular disease. Patients (n=40) with posttreatment WB-MRI data had a total lesion count of 150; this value was reduced to 45 (30%) following treatment with pamidronate. A total of 17 patients (42.5%) had complete resolution of all lesions, constituting good response; 10 (25%) and 4 (10%) patients had a moderate and mild response, respectively; 9 patients (22.5%) had no response. Patients (n=9) with vertebral disease at first CNO presentation also achieved good pamidronate response, with 82.3% of vertebral lesions (14 of 17 lesions) resolving completely. Treatment was escalated to anti-tumor necrosis factor (TNF) agents in patients with suboptimal bisphosphonate response. Pamidronate was relatively well-tolerated by patients, with just 2 of the 46 patients discontinuing treatment due to infusion-related side effects.

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These data support treatment with pamidronate following suboptimal response to NSAIDs, although bisphosphonates were also effective as first-line treatment in the presence of spinal or mandibular lesions. WB-MRI was also confirmed as an effective marker of disease activity in CNO. Research in a prospective cohort is necessary to confirm the efficacy of pamidronate and to compare pamidronate with anti-TNF agents in the treatment of CNO.


Bhat CS, Roderick M, Sen ES, Finn A, Ramanan AV. Efficacy of pamidronate in children with chronic non-bacterial osteitis using whole body MRI as a marker of disease activity. Pediatr Rheumatol Online J. 2019;17:35.