Expert consensus: Sterile bone inflammation to be called ‘chronic non-bacterial osteitis’
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Key takeaways:
- MRI or CT plus nuclear imaging should be used for evaluation.
- NSAIDs or COX-2 inhibitors should be first-line treatments.
The label “chronic non-bacterial osteitis” should be used to describe sterile bone inflammation in adults, and NSAIDs or cyclooxygenase-2 inhibitors are the recommended first-line treatments, according to a new expert consensus.
“Sterile bone inflammation (SBI) represents a rare and heterogeneous disease spectrum that affects children and adults,” Elizabeth M. Winter, MD, PhD, of the Center for Bone Quality at Leiden University Medical Center, in the Netherlands, and colleagues wrote in Annals of the Rheumatic Diseases. “Various terms are currently in use to describe patients with SBI, including chronic non-bacterial osteomyelitis, chronic recurrent multifocal osteomyelitis, synovitis, acne, pustulosis, hyperostosis, osteitis syndrome, diffuse sclerosing osteomyelitis, pustulotic arthro-osteitis, sternocostoclavicular hyperostosis and more.
“The clinical management of SBI presents major challenges,” they added. “Unifying diagnostic criteria are lacking, pathophysiology is largely unknown, and there are no standard outcome measures or evidence-based treatment modalities. ... The provision of care for patients with SBI is fragmented, spread across diverse medical disciplines such as rheumatology, orthopedic surgery and endocrinology, with wide variety in (off-label) treatment strategies. Clearly, consensus recommendations and a research agenda are necessary steps towards clinical advancement for SBI.”
To develop expert consensus recommendations for defining, diagnosis and treating sterile bone inflammation, Winter and colleagues at Leiden University Medical Center began with a physician survey on current clinical practices. The authors used the results of this survey to determine domains of interest for subsequent recommendations, and conducted systematic literature reviews on each domain.
A “diverse and inclusive” expert panel, including patient representatives, was convened for two rounds of the Delphi consensus process and a total of three meetings, according to the authors. Panel members evaluated the final recommendations using a 10-point Likert scale.
Noting a “confusing, inconvenient and burdensome” proliferation of different names describing SBI in adults, such as synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome, the panel decided on a single overarching name for clinical and research use: “chronic non-bacterial osteitis” (CNO), which falls in line with recent use of “chronic non-bacterial osteomyelitis” in pediatrics, the authors wrote.
“‘Chronic non-bacterial osteomyelitis’ effectively captures the core disease feature, is short and inclusive and has recently been adopted in the pediatric community,” Winger and colleagues wrote. “However, the panel perceives that the term ‘osteitis’ better suits the pathology than ‘osteomyelitis.
“For pediatric CNO, a transition from ‘osteomyelitis’ to ‘osteitis’ is also anticipated,” they added. “The panel recommends discontinuing the use of other historical names, both in adults and children.”
In addition to more than 15 recommendations for diagnosis and treatment, the panel developed three general recommendations for managing the condition:
- Consider referral to an expert center for all adult patients with CNO and refer difficult-to-treat patients if not done initially.
- Adults with CNO should be diagnosed and treated by a multidisciplinary team, led by an expert in this disease, preferably a rheumatologist. In the absence of a rheumatologist, a specialist with expertise in autoinflammatory and bone-related disorders should assume this role. The team should involve musculoskeletal imaging experts and other medical specialists according to the presence of additional features.
- Aim for long-term follow-up in all patients. When follow-up is discontinued, inform patients that their condition may return with similar but different features and involvement sites in the future.
Either MRI, or CT plus nuclear imaging, were recommended for initial assessment of suspected CNO in adults, while whole-body imaging may also be considered.
As first-line treatment, the panel recommended NSAIDs or cyclooxygenase-2 inhibitors at the maximum approved dosage that can be tolerated. The the preferred second-line treatment is intravenous bisphosphonates, or TNF inhibitors or conventional synthetic disease-modifying anti-rheumatic drugs, depending on the patient. Adding or advancing to second-line treatment is to be considered in cases of “spinal bone lesions with risk of vertebral collapse” or for patients who show “significant accumulated skeletal damage,” according to the authors.
“Moving forward, the next steps for this project involve the dissemination and implementation of the consensus recommendations, which requires extensive communication through relevant networks in rheumatology, endocrinology, orthopedics, radiology and pediatric rheumatology,” Winter and colleagues wrote. “The panel perceives they are relatively easy to implement, as the recommendations pertain to relatively low patient numbers and were developed considering differences in the availability of diagnostic tests and treatment between health care systems.
“Despite being flexible, the recommendations offer a structured overview of diagnostic and management considerations for clinicians and helps patients understand what to expect,” they added. “A potential challenge may arise from the limited reimbursement and accessibility of [TNF inhibitors] in certain regions. However, alternatives to [TNF inhibitors] are proposed. Anticipating future revisions of the recommendations, the panel hopes for further advancements in research to provide a more robust scientific foundation for updates.”
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