Table 27. Summary of recommendations.

	Recommendation	Conditional Recommendation	Insufficient evidence
Diagnosis of PDB
X-rays	X-rays of abdomen, skull, facial bone and tibia recommended
Radionuclide bone scans	To fully determine extent of metabolically active disease
MRI and CT	Not recommended for diagnosis	May be considered to evaluate complications
ALP	First line biochemical test for metabolically active PDB in combination with LFT
PINP, BALP, NTX		Second line tests when suspicion of metabolically active disease is high and ALP is normal
Bisphosphonate treatment
Bone pain	Recommended for the treatment of bone pain
Quality of life			Insufficient evidence; treatment not recommended
Fracture prevention			Insufficient evidence; treatment not recommended
Progression of osteoarthritis			Insufficient evidence; treatment not recommended
Progression of hearing loss			Insufficient evidence; treatment not recommended
Blood loss during elective Orthopaedic surgery			Insufficient evidence; treatment not recommended
Bone deformity			Insufficient evidence; treatment not recommended
Neurological symptoms		Calcitonin or bisphosphonates may be considered as part of the treatment package
Asymptomatic patients with increased metabolic activity		Bisphosphonates may be considered, but clinical benefit unclear.
Neoplastic transformation			Insufficient evidence; treatment not recommended
Adverse effects of bisphosphonates	Patients can be reassured about the favourable adverse event profile
Treatment strategy
Symptomatic or intensive bisphosphonate treatment	Treatment goal should be to control bone pain rather than normalise ALP
Route of neridronate administration	Intravenous and intramuscular both recommended
Other treatments
Calcitonin for bone pain		May be considered for short term treatment of bone pain
Denosumab for treatment of PDB			Insufficient evidence; treatment not recommended
Denosumab for giant cell tumour		May be considered for treatment of giant cell tumour which is unresectable
Predicting response to treatment
Predicting response of bone lesions	Measurement of PINP recommended to predict lesion extent defined by scintigraphy following treatment
Predicting response of pain	Measurement of biochemical markers is not recommended as a means of predicting response of bone pain
Non-pharmacological treatments
Fracture fixation	Surgery is recommended for fixation of fractures through Pagetic bone
Hip or knee arthroplasty	Recommended for patients with PDB who with OA where medical treatment is inadequate
Osteotomy		May be considered or patients with PDB with OA where medical treatment is inadequate