The first international consensus recommendations for adult chronic nonbacterial osteitis (CNO) may provide unified diagnostic criteria and treatment protocols.

The recommendations were published in Annals of Rheumatic Diseases. For initial imaging, the panel recommended magnetic resonance imaging, with [99mTc]Tc-HDP single-photon emission computed tomography/computed tomography (SPECT/CT) or positron-emission tomography/computed tomography (PET/CT) with a bone-seeking radiotracer as alternatives. Whole-body imaging should be considered at diagnosis to identify clinically silent lesions.

Treatment should begin with NSAIDs/COX-2 inhibitors at maximum tolerated dose, evaluated after 2 to 4 weeks. Patients with spinal lesions risking vertebral collapse or significant skeletal damage may proceed directly to second-line treatments: intravenous bisphosphonates (preferred) or tumor necrosis factor–alpha inhibitors, with response assessed at 3 to 6 months.

The guidelines established four key treatment goals: pain relief, maintaining/regaining functional capacity, reducing inflammation, and preventing structural damage. Routine bone biopsies were not recommended except for cases with inconclusive imaging or suspected malignancy/infection.

Long-term follow-up was advised for all patients, with visits recommended every 3 to 6 months initially and extending to 12 to 24 months after stabilization.

The recommendations, endorsed by European medical societies including The European Calcified Tissue Society, were developed through systematic evidence review. The panel acknowledged limitations in available research, as recommendations relied primarily on expert consensus as a result of the condition's rarity.

These guidelines aimed to standardize care globally while establishing foundations for international patient registries and multicenter trials.