Patient-reported effectiveness and safety of Pamidronate in NSAIDs-refractory chronic recurrent multifocal osteomyelitis in children

Efficacy and Safety of Bisphosphonates in Chronic Non-bacterial Osteomyelitis of the Mandible: A Systematic Review

Chronic non-bacterial osteomyelitis (CNO) of the mandible, often called diffuse sclerosing osteomyelitis (DSO) in Maxillofacial and Dental literature, is a rare condition characterized by sterile osteomyelitis affecting the mandible. This condition is part of the chronic recurrent multifocal osteomyelitis (CRMO)/synovitis, acne, pustulosis, hyperostosis, and osteomyelitis (SAPHO) spectrum. However, because mandibular involvement may present as unifocal disease, it deserves special attention. Unfortunately, the rarity of this disorder, along with a general lack of awareness, has led to numerous unnecessary and ineffective surgical interventions in the past. While some of these lesions may resolve on their own with only symptomatic management with NSAIDs, there is increasing evidence that lesions refractory to NSAIDs can respond well to bisphosphonates (BPNs). The authors conducted a systematic review following PRISMA guidelines to investigate the effectiveness of BPNs for CNO/SAPHO of the mandible and to assess potential adverse reactions, particularly medication-related osteonecrosis of the jaw (MRONJ). In this review, we identified one randomized controlled trial and nine case series describing the use of bisphosphonates in treating mandibular CNO/SAPHO. While heterogeneity among the studies precluded the extraction of statistically relevant information, BPNs are an effective treatment for mandibular CNO with minimal chance of jaw osteonecrosis and disturbance to the growing skeleton.

Evaluation and analysis of efficacy in bisphosphonate treatment of chronic nonbacterial osteomyelitis

OBJECTIVES

This study aimed to analyze the influence of drug factors on the efficacy of bisphosphonate for chronic nonbacterial osteomyelitis to provide a reference for clinical treatment and promote clinical rational drug use by evaluation of effectiveness and safety of bisphosphonate treatment of chronic nonbacterial osteomyelitis.

METHODS

Literature on the treatment of chronic nonbacterial osteomyelitis by using bisphosphonate was collected and analyzed from PubMed, Medline, Embase, Cochrane, ISI Web of Knowledge, CNKI, VIP, and Wanfang databases.

RESULTS

A total of 489 cases were collected, with an average complete response rate of clinical presentation, laboratory tests and imaging findings of 80.37%, 80.56% and 79.22%, respectively. Except for opadronate, risedronate, ibandronate, pamidronate, alendronate, neidronate and zoledronate showed good efficacy, and the average complete response rates were 100%, 100%, 81.64%, 87.50%, 69.23% and 69.23%, respectively.The study found that in the pamidronate group, the average complete response rate of 0.5-1 mg/kg (maximum single dose≤60 mg) subgroup and the frequency of administration once every 3 months subgroup were better than other subgroups.

CONCLUSIONS

Bisphosphonate could be used to treat chronic nonbacterial osteomyelitis, which of efficacy were affected by different drug types, dose and frequency of administration. The optimal dose and frequency of administration of pamidronate were 0.5-1 mg/kg (maximum single dose≤60 mg) and once every 3 months, respectively.

Chronic non-bacterial osteomyelitis (CNO) and chronic recurrent multifocal osteomyelitis (CRMO) with a focus on pamidronate therapy

Chronic recurrent multifocal osteomyelitis (CRMO), also called chronic nonbacterial osteomyelitis (CNO) or nonbacterial osteomyelitis (NBO), is a rare autoinflammatory bone disease of unknown etiology. However, the number of patients properly diagnosed would increase with better knowledge of the disease. In this regard, whole-body magnetic resonance imaging (WB MRI) has been found to be a better predictor of active lesions than clinical examination. Importantly, the RINBO index (radiologic index for NBO) quantifies the involvement based on the WB MRI. Further, a chronic nonbacterial osteomyelitis MRI scoring (CROMRIS) has been developed as an online tool for assessing WB MRI. The therapy consists of non-steroidal anti-inflammatory drugs (NSAIDs), bisphosphonates (pamidronate, zoledronate, etc.) and other drugs, including biologics. Pamidronate is an appropriate and safe therapy. The first pilot prospective randomised controlled trial (RCT) on pamidronate vs. placebo was carried out in adults. No RCT has been done in children yet. Besides RCTs, there are a number of issues to be explored in future, i.e. predictors of therapy effect, optimal therapy duration, predictors of therapy discontinuation and evaluation of optimal therapy protocol. Recently, the CNO clinical disease activity score (CDAS) was constructed and validated but the classification criteria are still being developed. As collaboration on this rare disease is essential, a prospective Chronic Nonbacterial Osteomyelitis International Registry (CHOIR) was established to generate future comparative effectiveness research data.