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Within my Diabetic foot team, we tend to infuse Pamidronate asap at the same time as immobilisation upon detection of an acute Charcot.
However, after chatting to a member of a local Orthopaedic team recently, they have been using the osteopaenia that comes with the Charcot to their advantage by casting the foot and ankle (normal 'serial' type casting) with the Charcot still active until they acheive a 'good' position. I don't even think they use Pamidronate.
This 'moulding' whilst the process is still active would seem to me to make a lot of sense and if you infused with Pamidronate only once the foot/ankle was in a good position, this would seem perfect!?
I haven't done a lit. search on this yet, but if anyone had any evidence-based rationale for timing of Pamidronate infusion or has had similarly good results with 'moulding', I'd be pleased to hear!
While the use of a bisphosphonate like pamidronate makes some degree of sense in the early stages of Charcot, there are few data to identify when or if it has significant benefit. Recent discussions surrounding modulation of another pathway, this one involving osteoprotegerin (OPG) and RANK-L, might prove more therapeutically beneficial. The best potential pharmaceutical candidate presently available for this is intranasal calcitonin. If you want a bit more on this, I would direct you to:
Jeffcoate, W. (2004). Vascular calcification and osteolysis in diabetic neuropathy-is RANK-L the missing link? Diabetologia, 47(9), 1488-1492.
Jeffcoate WJ, Game F, Cavanagh PR The role of proinflammatory cytokines in the cause of neuropathic osteoarthropathy (acute Charcot foot) in diabetes. Lancet. 366(9502):2058-61, 2005 Dec 10.
Bisphosponate drugs including, Zometa, Aredia & Fosamax , plus others are quite helpful, if the patient doesn't get "Dead Jaw" Osteonecrosis of the jaw and potentially affecting other joints. It has been reported by the International Multiple Myeloma Foundation that 1+/10 will get the condition and it is devastating to the patient's life. Much worse than the underlying condition. Read the articles on mpowelllaw.com and decide if you are comfortable prescribing these medications.
Michael Bilinsky D.P.M
It would certainly seem that intranasal calcitonin would be a better arrangement, purely from a delivery point of view more than anything else as it takes 3-4 hours to inffuse the Pamidronate and it has to be done as a day-case appointment, incurring a waiting list of sorts!
As I am a Podiatrist in the UK, I do not prescribe this drug myself, rather the Consultant Diabetologists within the team instigate it. I have to say, it is used on all active Charcot (we probably see between 1 and 3 every month), but there has been no lock-jaw and the BNF (British National Formulary) does not list it as a complication (though it does have associated complications like myalgia etc), but I will look on the website for more info!
Have either of you had experience of serial casting the foot/ankle into a 'better' position whilst the Charcot is still active and before trying to stabilise the bone pharmacologically?
quite helpful, if the patient doesn't get "Dead Jaw" Osteonecrosis of the jaw and potentially affecting other joints.
Thats now the subject of litigation:
CTV.ca are reporting: Fosamax users seek class-action status
Quote:
Lawyers for Fosamax users who believe their jaws were damaged by the osteoporosis drug on Friday asked a federal judge to order Merck & Co. to provide a dental monitoring program for the drug's users.
The lawyers made the suggestion to U.S. District Judge John F. Keenan as they argued for the case to be certified as a class-action, in order to pursue claims by users who believe the drug caused osteonecrosis of the jaw, a condition in which portions of the jaw bone die, sometimes leaving the bone exposed.
Timothy M. O'Brien, a lawyer for plaintiffs, said hundreds of thousands of patients would benefit from a dental monitoring program that would include regular dental screenings, X-rays and lab tests, all aimed at preventing the need for dental surgery.
Paul Strain, a Merck attorney, called Fosamax a "life altering and life saving drug" that helps to prevent the kind of bone fractures that can hasten the deaths of people as they age. He said the drug was a pioneer 11 years ago.
Strain also said there was no proven link between degeneration of the jaw bone in some patients and Fosamax.
Damage to the jaw bone can result in many ways, including from using steroids, from diseases or weaknesses in the body and from poor dental hygiene.
O'Brien said as many as one in every 296 patients who use Fosamax develop the severe damage to the jaw, though Merck disputed the figure. O'Brien said jaws were more susceptible to damage because they are used so frequently and are under greater stress than most bones.
Keenan did not immediately rule after hearing arguments.
Vance Andrus, another lawyer for the plaintiffs, argued a class-action certification would allow for a trial where a jury could decide whether Fosamax is toxic and hazardous and whether Merck was negligent and should have warned users of dangers.
The FDA have just issued this warning: Information for Healthcare Professionals
Bisphosphonates (marketed as Actonel, Actonel+Ca, Aredia, Boniva, Didronel, Fosamax, Fosamax+D, Reclast, Skelid, and Zometa)
Quote:
FDA ALERT [1/7/2008]: FDA is highlighting the possibility of severe and sometimes incapacitating bone, joint, and/or muscle (musculoskeletal) pain in patients taking bisphosphonates. Although severe musculoskeletal pain is included in the prescribing information for all bisphosphonates, the association between bisphosphonates and severe musculoskeletal pain may be overlooked by healthcare professionals, delaying diagnosis, prolonging pain and/or impairment, and necessitating the use of analgesics.
The severe musculoskeletal pain may occur within days, months, or years after starting a bisphosphonate. Some patients have reported complete relief of symptoms after discontinuing the bisphosphonate, whereas others have reported slow or incomplete resolution. The risk factors for and incidence of severe musculoskeletal pain associated with bisphosphonates are unknown.
This severe musculoskeletal pain is in contrast to the acute phase response characterized by fever, chills, bone pain, myalgias, and arthralgias that sometimes accompanies initial administration of intravenous bisphosphonates and may occur with initial exposure to once-weekly or once-monthly doses of oral bisphosphonates. The symptoms related to the acute phase response tend to resolve within several days with continued drug use.
Healthcare professionals should consider whether bisphosphonate use might be responsible for severe musculoskeletal pain in patients who present with these symptoms and consider temporary or permanent discontinuation of the drug.
Pamidronate infusion timing in Charcot Rx
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