When is calcitonin (calcitonin) contraindicated?

Contraindications for Calcitonin Use

Calcitonin is contraindicated in patients with hypersensitivity to calcitonin-salmon or any of its excipients, as reactions can include anaphylactic shock, anaphylaxis, bronchospasm, and swelling of the tongue or throat. 1

Primary Contraindications

Calcitonin should not be used in the following situations:

1. Hypersensitivity reactions:

   • History of allergic reactions to calcitonin-salmon
   • Previous anaphylactic shock or anaphylaxis with calcitonin
   • Bronchospasm or swelling of tongue/throat with previous use 1

2. Specific patient populations:

   • Early postmenopausal women (less than 5 years post-menopause) 1
   • Patients who can tolerate other osteoporosis treatments 2

Clinical Considerations for Avoiding Calcitonin

Cirrhosis and Portal Hypertension

• Oral alendronate should be avoided in patients with cirrhosis who may have portal hypertension and esophageal varices due to risk of precipitating variceal hemorrhage 2
• While this specifically refers to alendronate, it highlights the need for caution with any medication in patients with advanced liver disease

Hypocalcemia

• Hypocalcemia must be corrected before initiating therapy with calcitonin
• Patients with disorders affecting mineral metabolism (such as vitamin D deficiency) should be effectively treated before starting calcitonin 1
• Monitoring of serum calcium and symptoms of hypocalcemia is recommended during therapy

Nasal Adverse Reactions

• Calcitonin nasal spray should be discontinued if severe ulceration of the nasal mucosa occurs (ulcers >1.5 mm in diameter or penetrating below mucosa)
• Nasal ulcers associated with heavy bleeding warrant discontinuation 1

Efficacy Limitations

Calcitonin should be avoided as a first-line treatment due to:

1. Limited efficacy data:

   • Fracture reduction efficacy has not been clearly demonstrated 1
   • Should be reserved for patients for whom alternative treatments are not suitable 2

2. Cancer concerns:

   • Possible association between malignancy and calcitonin-salmon use 1, 3
   • This association has significantly limited its clinical application

3. Better alternatives available:

   • Bisphosphonates and newer agents like denosumab have largely replaced calcitonin in osteoporosis treatment 3
   • According to ACOG guidelines, calcitonin should only be used in women with less serious osteoporosis who cannot tolerate other treatments 2

Practical Considerations

• Administration challenges: Injectable forms are less preferred by patients 3
• Nasal spray formulations require careful monitoring for mucosal changes 1
• Need for periodic reevaluation of continued therapy due to malignancy concerns 1

Special Populations

• Liver disease patients: Anabolic steroids should be avoided in patients with chronic liver disease, but calcitonin may be considered as part of combination therapy in patients with primary biliary cirrhosis 2

• Postmenopausal women: Calcitonin should only be used in women more than five years post-menopause 2

Remember that when calcitonin is used, it should be administered with adequate calcium (at least 1000 mg elemental calcium per day) and vitamin D (at least 400 International Units per day) supplementation 1.