Expert consensus recommendations for the diagnosis and treatment of chronic non-bacterial osteitis (CNO) in adults

Elizabeth Winter; Olaf Dekkers; Caroline Andreasen; Salvatore D'Angelo; Natasha Appelman-Dijkstra; Simone Appenzeller; Gunter Assmann; Judith Bubbear; Oana Bulaicon; Roland Chapurlat; Varvara Choida; Gavin P.R. Clunie; Dimitrios Daoussis; Torsten Diekhoff; Marcel Flendrie; Olivier Fogel; Roba Ghossan; Hermann Girschick; Femke van Haalen; Neveen Hamdy; Barbara Hauser; Christian Hedrich; Philip Helliwell; Kay Geert Hermann; Antonella Insalaco; Anne Grethe Jurik; Mitsumasa Kishimoto; Willem Lems; Paivi Miettunen; Burkhard Muche; Ana Navas Cañete; Natalia Palmou-Fontana; Frits Smit; James Teh; Charlotte Verroken; Kurt de Vlam; Daniel Wendling; Wei Zhou; Hans Georg Zmierczak; Anne Leerling

doi:10.1136/ard-2024-226446

Expert consensus recommendations for the diagnosis and treatment of chronic non-bacterial osteitis (CNO) in adults

Elizabeth Winter^*, Olaf Dekkers, Caroline Andreasen, Salvatore D'Angelo, Natasha Appelman-Dijkstra, Simone Appenzeller, Gunter Assmann, Judith Bubbear, Oana Bulaicon, Roland Chapurlat, Varvara Choida, Gavin P.R. Clunie, Dimitrios Daoussis, Torsten Diekhoff, Marcel Flendrie, Olivier Fogel, Roba Ghossan, Hermann Girschick, Femke van Haalen, Neveen HamdyBarbara Hauser, Christian Hedrich, Philip Helliwell, Kay Geert Hermann, Antonella Insalaco, Anne Grethe Jurik, Mitsumasa Kishimoto, Willem Lems, Paivi Miettunen, Burkhard Muche, Ana Navas Cañete, Natalia Palmou-Fontana, Frits Smit, James Teh, Charlotte Verroken, Kurt de Vlam, Daniel Wendling, Wei Zhou, Hans Georg Zmierczak, Anne Leerling

^*Corresponding author for this work

Research output: Contribution to journal/Conference contribution in journal/Contribution to newspaper › Journal article › Research › peer-review

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Abstract

Background: There is considerable practice variation in labelling, diagnosis and treatment of adults with sterile bone inflammation. We developed a expert consensus recommendations on the disease definition, diagnosis and treatment of this rare condition. Methods: Systematic literature review and Grading of Recommendations, Assessment, Development and Evaluations-based appraisal of evidence, two Delphi surveys and three digital and in-person consensus meetings with a multidisciplinary expert panel and patient representatives. Results: A consensus disease definition was developed and the term ’chronic non-bacterial osteitis’ (CNO) is proposed to describe adults with sterile bone inflammation. For initial imaging evaluation of adults with suspected CNO, the panel recommends MRI or otherwise CT combined with nuclear imaging. Whole-body imaging at initial evaluation can be considered for diagnostic and prognostic purposes. Suggested first-line treatment in adults with active CNO includes nonsteroidal anti-inflammatory drugs/cyclooxygenase 2-inhibitors. Second-line treatment preferably consists of intravenous bisphosphonates, and otherwise tumour necrosis factor-α inhibitors. Choice between them should be individualised, considering the presence of additional inflammatory features. The panel further discusses outcome measures, follow-up and management of adverse events and complications. Conclusions and future perspectives: These expert consensus recommendations are intended to support healthcare professionals worldwide in their care for adults with CNO. They also lay the groundwork for establishing international patient registries, translational research lines and multicentre trials, all of which are urgently required.

Original language	English
Journal	Annals of the Rheumatic Diseases
Volume	84
Issue	2
Pages (from-to)	169-187
Number of pages	19
ISSN	0003-4967
DOIs	https://doi.org/10.1136/ard-2024-226446
Publication status	Published - Feb 2025

Keywords

epidemiology
health care
magnetic resonance imaging
outcome and process assessment
tumor necrosis factors

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10.1136/ard-2024-226446Licence: CC BY

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Winter, E., Dekkers, O., Andreasen, C., D'Angelo, S., Appelman-Dijkstra, N., Appenzeller, S., Assmann, G., Bubbear, J., Bulaicon, O., Chapurlat, R., Choida, V., Clunie, G. P. R., Daoussis, D., Diekhoff, T., Flendrie, M., Fogel, O., Ghossan, R., Girschick, H., van Haalen, F., ... Leerling, A. (2025). Expert consensus recommendations for the diagnosis and treatment of chronic non-bacterial osteitis (CNO) in adults. Annals of the Rheumatic Diseases, 84(2), 169-187. https://doi.org/10.1136/ard-2024-226446

@article{3463e2ba0685494390919a20d21fcd7d,

title = "Expert consensus recommendations for the diagnosis and treatment of chronic non-bacterial osteitis (CNO) in adults",

abstract = "Background: There is considerable practice variation in labelling, diagnosis and treatment of adults with sterile bone inflammation. We developed a expert consensus recommendations on the disease definition, diagnosis and treatment of this rare condition. Methods: Systematic literature review and Grading of Recommendations, Assessment, Development and Evaluations-based appraisal of evidence, two Delphi surveys and three digital and in-person consensus meetings with a multidisciplinary expert panel and patient representatives. Results: A consensus disease definition was developed and the term {\textquoteright}chronic non-bacterial osteitis{\textquoteright} (CNO) is proposed to describe adults with sterile bone inflammation. For initial imaging evaluation of adults with suspected CNO, the panel recommends MRI or otherwise CT combined with nuclear imaging. Whole-body imaging at initial evaluation can be considered for diagnostic and prognostic purposes. Suggested first-line treatment in adults with active CNO includes nonsteroidal anti-inflammatory drugs/cyclooxygenase 2-inhibitors. Second-line treatment preferably consists of intravenous bisphosphonates, and otherwise tumour necrosis factor-α inhibitors. Choice between them should be individualised, considering the presence of additional inflammatory features. The panel further discusses outcome measures, follow-up and management of adverse events and complications. Conclusions and future perspectives: These expert consensus recommendations are intended to support healthcare professionals worldwide in their care for adults with CNO. They also lay the groundwork for establishing international patient registries, translational research lines and multicentre trials, all of which are urgently required.",

keywords = "epidemiology, health care, magnetic resonance imaging, outcome and process assessment, tumor necrosis factors",

author = "Elizabeth Winter and Olaf Dekkers and Caroline Andreasen and Salvatore D'Angelo and Natasha Appelman-Dijkstra and Simone Appenzeller and Gunter Assmann and Judith Bubbear and Oana Bulaicon and Roland Chapurlat and Varvara Choida and Clunie, {Gavin P.R.} and Dimitrios Daoussis and Torsten Diekhoff and Marcel Flendrie and Olivier Fogel and Roba Ghossan and Hermann Girschick and {van Haalen}, Femke and Neveen Hamdy and Barbara Hauser and Christian Hedrich and Philip Helliwell and Hermann, {Kay Geert} and Antonella Insalaco and Jurik, {Anne Grethe} and Mitsumasa Kishimoto and Willem Lems and Paivi Miettunen and Burkhard Muche and Ca{\~n}ete, {Ana Navas} and Natalia Palmou-Fontana and Frits Smit and James Teh and Charlotte Verroken and {de Vlam}, Kurt and Daniel Wendling and Wei Zhou and Zmierczak, {Hans Georg} and Anne Leerling",

year = "2025",

month = feb,

doi = "10.1136/ard-2024-226446",

language = "English",

volume = "84",

pages = "169--187",

journal = "Annals of the Rheumatic Diseases",

issn = "0003-4967",

publisher = "Elsevier BV",

number = "2",

}

Winter, E, Dekkers, O, Andreasen, C, D'Angelo, S, Appelman-Dijkstra, N, Appenzeller, S, Assmann, G, Bubbear, J, Bulaicon, O, Chapurlat, R, Choida, V, Clunie, GPR, Daoussis, D, Diekhoff, T, Flendrie, M, Fogel, O, Ghossan, R, Girschick, H, van Haalen, F, Hamdy, N, Hauser, B, Hedrich, C, Helliwell, P, Hermann, KG, Insalaco, A, Jurik, AG, Kishimoto, M, Lems, W, Miettunen, P, Muche, B, Cañete, AN, Palmou-Fontana, N, Smit, F, Teh, J, Verroken, C, de Vlam, K, Wendling, D, Zhou, W, Zmierczak, HG & Leerling, A 2025, 'Expert consensus recommendations for the diagnosis and treatment of chronic non-bacterial osteitis (CNO) in adults', Annals of the Rheumatic Diseases, vol. 84, no. 2, pp. 169-187. https://doi.org/10.1136/ard-2024-226446

Expert consensus recommendations for the diagnosis and treatment of chronic non-bacterial osteitis (CNO) in adults. / Winter, Elizabeth; Dekkers, Olaf; Andreasen, Caroline et al.
In: Annals of the Rheumatic Diseases, Vol. 84, No. 2, 02.2025, p. 169-187.

Research output: Contribution to journal/Conference contribution in journal/Contribution to newspaper › Journal article › Research › peer-review

TY - JOUR

T1 - Expert consensus recommendations for the diagnosis and treatment of chronic non-bacterial osteitis (CNO) in adults

AU - Winter, Elizabeth

AU - Dekkers, Olaf

AU - Andreasen, Caroline

AU - D'Angelo, Salvatore

AU - Appelman-Dijkstra, Natasha

AU - Appenzeller, Simone

AU - Assmann, Gunter

AU - Bubbear, Judith

AU - Bulaicon, Oana

AU - Chapurlat, Roland

AU - Choida, Varvara

AU - Clunie, Gavin P.R.

AU - Daoussis, Dimitrios

AU - Diekhoff, Torsten

AU - Flendrie, Marcel

AU - Fogel, Olivier

AU - Ghossan, Roba

AU - Girschick, Hermann

AU - van Haalen, Femke

AU - Hamdy, Neveen

AU - Hauser, Barbara

AU - Hedrich, Christian

AU - Helliwell, Philip

AU - Hermann, Kay Geert

AU - Insalaco, Antonella

AU - Jurik, Anne Grethe

AU - Kishimoto, Mitsumasa

AU - Lems, Willem

AU - Miettunen, Paivi

AU - Muche, Burkhard

AU - Cañete, Ana Navas

AU - Palmou-Fontana, Natalia

AU - Smit, Frits

AU - Teh, James

AU - Verroken, Charlotte

AU - de Vlam, Kurt

AU - Wendling, Daniel

AU - Zhou, Wei

AU - Zmierczak, Hans Georg

AU - Leerling, Anne

PY - 2025/2

Y1 - 2025/2

N2 - Background: There is considerable practice variation in labelling, diagnosis and treatment of adults with sterile bone inflammation. We developed a expert consensus recommendations on the disease definition, diagnosis and treatment of this rare condition. Methods: Systematic literature review and Grading of Recommendations, Assessment, Development and Evaluations-based appraisal of evidence, two Delphi surveys and three digital and in-person consensus meetings with a multidisciplinary expert panel and patient representatives. Results: A consensus disease definition was developed and the term ’chronic non-bacterial osteitis’ (CNO) is proposed to describe adults with sterile bone inflammation. For initial imaging evaluation of adults with suspected CNO, the panel recommends MRI or otherwise CT combined with nuclear imaging. Whole-body imaging at initial evaluation can be considered for diagnostic and prognostic purposes. Suggested first-line treatment in adults with active CNO includes nonsteroidal anti-inflammatory drugs/cyclooxygenase 2-inhibitors. Second-line treatment preferably consists of intravenous bisphosphonates, and otherwise tumour necrosis factor-α inhibitors. Choice between them should be individualised, considering the presence of additional inflammatory features. The panel further discusses outcome measures, follow-up and management of adverse events and complications. Conclusions and future perspectives: These expert consensus recommendations are intended to support healthcare professionals worldwide in their care for adults with CNO. They also lay the groundwork for establishing international patient registries, translational research lines and multicentre trials, all of which are urgently required.

AB - Background: There is considerable practice variation in labelling, diagnosis and treatment of adults with sterile bone inflammation. We developed a expert consensus recommendations on the disease definition, diagnosis and treatment of this rare condition. Methods: Systematic literature review and Grading of Recommendations, Assessment, Development and Evaluations-based appraisal of evidence, two Delphi surveys and three digital and in-person consensus meetings with a multidisciplinary expert panel and patient representatives. Results: A consensus disease definition was developed and the term ’chronic non-bacterial osteitis’ (CNO) is proposed to describe adults with sterile bone inflammation. For initial imaging evaluation of adults with suspected CNO, the panel recommends MRI or otherwise CT combined with nuclear imaging. Whole-body imaging at initial evaluation can be considered for diagnostic and prognostic purposes. Suggested first-line treatment in adults with active CNO includes nonsteroidal anti-inflammatory drugs/cyclooxygenase 2-inhibitors. Second-line treatment preferably consists of intravenous bisphosphonates, and otherwise tumour necrosis factor-α inhibitors. Choice between them should be individualised, considering the presence of additional inflammatory features. The panel further discusses outcome measures, follow-up and management of adverse events and complications. Conclusions and future perspectives: These expert consensus recommendations are intended to support healthcare professionals worldwide in their care for adults with CNO. They also lay the groundwork for establishing international patient registries, translational research lines and multicentre trials, all of which are urgently required.

KW - epidemiology

KW - health care

KW - magnetic resonance imaging

KW - outcome and process assessment

KW - tumor necrosis factors

UR - http://www.scopus.com/inward/record.url?scp=85213689810&partnerID=8YFLogxK

U2 - 10.1136/ard-2024-226446

DO - 10.1136/ard-2024-226446

M3 - Journal article

C2 - 39608805

AN - SCOPUS:85213689810

SN - 0003-4967

VL - 84

SP - 169

EP - 187

JO - Annals of the Rheumatic Diseases

JF - Annals of the Rheumatic Diseases

IS - 2

ER -

Expert consensus recommendations for the diagnosis and treatment of chronic non-bacterial osteitis (CNO) in adults

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