# Long-Term Denosumab Treatment in Adults with Juvenile Paget Disease

## TL;DR

Long-term denosumab treatment in adults with Juvenile Paget Disease effectively manages bone issues but may not prevent vision problems.

## Contribution

Demonstrates the long-term safety and efficacy of denosumab in treating JPD, a rare bone disorder.

## Key findings

- Denosumab normalized alkaline phosphatase levels and improved mobility in two patients over 12-13.5 years.
- Bone pain decreased and no new fractures occurred during long-term treatment.
- Vision loss occurred in one patient, suggesting retinopathy may not be prevented by denosumab.

## Abstract

Juvenile Paget disease (JPD) is a very rare disease, mainly caused by biallelic inactivating mutations in the TNFRSF11B gene that encodes osteoprotegerin. Owing to its rarity, the treatment of JPD is largely empirical. Accelerated bone turnover as assessed by biochemical markers, such as alkaline phosphatase (ALP), can be suppressed by bisphosphonate treatment, but it relapses if bisphosphonate treatment is discontinued. In this report, we describe our experience with long-term denosumab treatment in two adults with JPD, homozygous for the “Balkan” mutation (966_969delTGACinsCTT) in TNFRSF11B. Subject 1 started denosumab in age 35 and subject 2 in age 34. Both continue treatment until today, for 13.5 and 12 years, respectively. ALP was steadily normalized in both. Bone pain decreased and mobility improved. Hearing did not further deteriorate and no new fracture occurred. Vision remained unchanged in subject 2, but subject 1 experienced sudden vision loss of the right eye at age 46, which was successfully managed with intravitreal treatment with anti-vascular endothelial growth factor medications. In conclusion, long-term denosumab administration in adults with JPD, who had been previously treated with bisphosphonates, was safe and effective in terms of the skeletal disease, but it may not prevent the emergence of retinopathy.