Treatment of Resistant Osteitis pubis with Pamidronate

Back in 2001, 3 subjects with resistant osteitis pubis had monthly infusions of 60 mg pamidronate – one for 3 months and 2 for 6 months. Two had no known cause and one had inflammatory arthritis. All recovered and had no recurrence of symptoms and in the 2 with bone scan changes- these changes resolved. Now this study has be replicated – cases with bone marrow edema were infused with 60 mg over 60 kg size and 30 mg under 60 kg size. Sadly, they were given one infusion initially and maybe a repeat at 3 months – a study I call “one shot wonders” – hardly sufficient to work well. Nonetheless, 5/8 were significantly improved and returned to sports and 1/8 was some improved. This confirms in my mind that it should be used in resistant osteitis pubis.

The earlier study is here:

J Rheumatol. 2001 Dec;28(12):2754-7.
Treatment of refractory symphysitis pubis with intravenous pamidronate.
Maksymowych WP(1), Aaron SL, Russell AS.

  • 3 recalcitrant cases – one with known inflammatory arthrtis; 2 were unknown
  • 2 had a positive bone scan
  • 2 had 3 monthly 60 mg pamidronate infusions; one had 6.
  • all resolved with no recurrence.

Present study:

Wedatilake, Thamindu, et al.
Treatment of osteitis pubis with pamidronate in athletes. International Musculoskeletal Medicine (2014). (in press)

Can’t get access to article so just have abstract:

  • 8 athletes- resistant osteitis pubis
  • Evidence of bone marrow edema on MRI
  • 60 mg pamidronate if >60 kg; 30 mg if <60 kg – IV usually in 250-500 mls over 4 hours
  • They gave one infusion and a second on at 3 months if not significantly better
  • 5 significantly improved and returned to sport; 1 some better
  • “Pain scores improved: (1) at rest (1.07 to 0.29, P = 0.10); (2) during activities of daily living (4.3 to 1.2, P = 0.004); and (3) during sport (8.1 to 1.2, P = 0.001).”
  • a previous study has found biphosponates have worked in bone marrow edema:
    Rheumatol Int. 2013 Jun;33(6):1397-402.
    Bisphosphonates or prostacyclin in the treatment of bone-marrow oedema syndrome of the knee and foot.
    Baier C1, Schaumburger J, Götz J, Heers G, Schmidt T, Grifka J, Beckmann J.
    They found: “Regarding bisphosphonates, four patients described pain release after the first infusion, another three after the second treatment and another two not until the third application, leaving one non-responder in the bisphosphonate treatment group.”

Comment – results look very encouraging. Giving one treatment I call a “one shot wonder” – woefully inadequate, yet pretending to do good.  I have written before on how pamidronate needs to be given a minimum of THREE times for other conditions:

I would suspect, like in the bone edema study where a subgroup did not get better until the third infusion, there would be more response if three monthly injections minimum had been given, and up to 6 monthly if necessary (as found in the first study). People have to have good teeth for pamidronate as it can rarely cause osteonecrosis of jaw (bacteria stick to bone more easily with pamidronate and can cause a jaw infection that leads to necrosis of jaw in rare cases). Rarely, it can cause an odd subtrochanteric fracture.



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