Table 17. Treating symptoms or increased metabolic activity in PDB.

Risk-benefit balance A strategy of intensive bisphosphonate therapy aimed at maintaining total ALP concentrations within the reference range performed similarly to a strategy of treatment with bisphosphonates and other drugs which aimed to control symptoms, with respect to the occurrence of clinical fractures, fractures through Pagetic bone, requirement for orthopaedic surgery, quality of life, bone pain and progression of progression of hearing loss. Quality of evidence Moderate Patient values and preferences Prevention of fractures and orthopaedic procedures, and improvements in bone pain, quality of life and prevention of progressive hearing loss are all highly valued by patients. Costs and use of resources Bisphosphonates are inexpensive drugs but intravenous therapy may involve additional support costs which may need to be considered. More frequent courses of therapy increase health care costs and resources as compared with less frequent courses of treatment. Recommendation Treatment aimed at improving symptoms is recommended over a treat-to-target strategy aimed at normalising total ALP in PDB.