Role of Calcitonin Nasal Spray in Treating Compression Fractures
Calcitonin nasal spray at a dose of 200 IU daily for 4 weeks is recommended for patients with acute osteoporotic spinal compression fractures (0-5 days after injury or symptom onset) who are neurologically intact. 1, 2
Acute Management (0-5 days post-fracture)
- Calcitonin nasal spray (200 IU daily) has been shown to reduce pain at 1,2,3, and 4 weeks in a clinically significant manner 1, 2
- Treatment should be initiated within 0-5 days after an identifiable event or onset of symptoms 3
- Alternate nostrils daily - start with left nostril on first day, then right nostril on second day, continuing to alternate 4
- Side effects are generally mild and may include dizziness 1, 2
Dosing and Administration
- The recommended dose is 200 IU daily for 4 weeks 1, 3
- Alternative administration routes include:
- Adequate calcium (1000 mg) and vitamin D (400 IU) supplementation should be given concurrently with calcitonin therapy 4, 3
Evidence for Pain Relief
- Multiple studies demonstrate that calcitonin significantly reduces acute pain associated with vertebral compression fractures 1, 5
- Pain relief typically begins within the first week of treatment and continues throughout the 4-week treatment period 1, 2
- Calcitonin may also be beneficial for chronic back pain following vertebral fractures 5
Long-term Management Considerations
- For longer-term treatment in established osteoporosis, nasal calcitonin in a 2-month-on and 2-month-off fashion for up to 12 months has shown benefit 3
- For persistent pain at L3 or L4 vertebral compression fractures, an L2 nerve root block is a treatment option 2
- Monitoring should include yearly bone mineral density (BMD) measurements to assess treatment response 6
- If BMD falls >4% per year in two successive years, treatment should be changed to another drug 6
Patient Selection
- Calcitonin nasal spray is indicated for postmenopausal women more than 5 years after menopause with low bone mass who refuse or cannot tolerate estrogens 4
- Contraindicated in patients with allergy to calcitonin-salmon 3
- Not recommended as first-line therapy for established osteoporosis due to limited long-term fracture prevention evidence 5
Prevention of Additional Fractures
- The PROOF study demonstrated that 200 IU daily nasal calcitonin reduced the risk of new vertebral fractures by 33% over 5 years 7
- For prevention of additional symptomatic fractures, ibandronate and strontium ranelate are recommended options 2
Limitations and Considerations
- Calcitonin is significantly more expensive than bisphosphonates (approximately eight times more expensive than alendronate) 6
- Bioavailability of nasal calcitonin is only about 3-5% of injectable forms 4, 7
- Nasal administration is better tolerated than injectable forms, with fewer side effects 7
- A nasal examination should be performed prior to starting treatment and if nasal complaints occur 4