What is the dosing regimen for calcitonin (salmon calcitonin) for the management of bone pain and compression fractures?

Short Course Calcitonin Dosing for Bone Pain and Compression Fractures

For patients with acute osteoporotic spinal compression fractures with correlating clinical signs and symptoms, calcitonin should be administered at a dose of 200 IU daily for 4 weeks. 1

Dosing Regimen Details

Nasal Administration (Preferred Route)

• Dose: 200 IU (one spray) daily 1, 2
• Duration: 4 weeks 1
• Administration technique:
  • Alternate nostrils daily 2
  • Hold bottle upright with head in upright position 2
  • Prime pump before first use only (not before each daily dose) 2

Alternative Administration Routes

• Suppositories: 200 IU daily (shown effective in studies) 1
• Subcutaneous/Intramuscular: 100 IU daily or every other day (less commonly used due to invasiveness) 3, 4

Efficacy for Acute Pain Management

Calcitonin provides rapid pain relief for acute vertebral compression fractures:

• Pain reduction begins within the first week of treatment 5, 6
• Number needed to treat is approximately 2 patients for pain relief at week 1 6
• Enables earlier mobilization compared to placebo 5

Clinical Application Algorithm

1. Confirm diagnosis: Verify osteoporotic spinal compression fracture on imaging with correlating clinical signs and symptoms suggesting acute injury (0-5 days after identifiable event or symptom onset) 1

2. Assess patient factors:

   • Ensure patient is neurologically intact 1
   • Check for contraindications (allergy to calcitonin-salmon) 1

3. Initiate calcitonin therapy:

   • Start 200 IU nasal calcitonin daily for 4 weeks 1
   • Monitor for side effects (mild dizziness most common) 1

4. Plan for long-term management:

   • Calcitonin is primarily for short-term pain management 7
   • Transition to more effective long-term osteoporosis therapy after the 4-week course 7
   • Consider bisphosphonates as first-line for long-term management (except in patients with esophageal varices or other contraindications) 1

Important Considerations

• Calcitonin is considered a second-line therapy for osteoporosis management but is valuable for acute pain control 1, 7
• The analgesic effect appears to work through central mechanisms rather than just through effects on bone remodeling 5
• While some studies show benefit with longer treatment periods (3-12 months), the strongest evidence supports the 4-week short course for acute pain management 1
• No weaning protocol is necessary when discontinuing calcitonin 7

Potential Pitfalls

• Do not rely on calcitonin alone for long-term fracture prevention; it has weaker data compared to other osteoporosis treatments 1
• Avoid using biochemical markers of bone turnover to monitor response to calcitonin therapy as these have not been consistently demonstrated to reflect clinical response 2
• Be aware that pain relief efficacy beyond 4 weeks is less clear due to substantial heterogeneity in studies 6