Calcitonin for Recurrent Compression Fractures
For patients with recurrent osteoporotic vertebral compression fractures, calcitonin should be administered at a dose of 200 IU daily for 4 weeks, either as nasal spray or suppositories, and should be initiated within 0-5 days after fracture onset for optimal pain relief. 1, 2
Dosage Recommendations
- For acute vertebral compression fractures, the recommended dose is 200 IU daily administered as nasal spray or suppositories for 4 weeks 2
- Alternative administration routes include 100 IU subcutaneously or intramuscularly every other day 2
- Treatment should be initiated within 0-5 days after symptom onset or identifiable fracture event for maximum efficacy 2
- Calcium and vitamin D supplementation should be administered concurrently with calcitonin therapy 2
Duration of Treatment
- For acute pain management, the initial treatment period is 4 weeks 2
- For longer-term treatment in established osteoporosis, nasal calcitonin can be administered in a 2-month-on and 2-month-off pattern for up to 12 months 2
- For prevention of additional fractures, treatment may need to continue for at least three years with yearly bone mineral density (BMD) measurements to monitor response 3
- If BMD falls >4% per year for two consecutive years, treatment should be changed to another agent 3
Efficacy for Pain Management
- Calcitonin significantly reduces acute pain in recent vertebral compression fractures, with benefits observed as early as week 1 of treatment 4
- Pain relief continues to improve through 4 weeks of treatment, with greater pain reduction during mobility than at rest 4, 5
- The number needed to treat for pain relief at week 1 is approximately two patients 4
- For chronic pain from older fractures, calcitonin shows limited efficacy, with only small improvements in mobility-related pain at 6 months 5
Side Effects and Monitoring
- Side effects are generally mild and include dizziness, nausea, and altered serum calcium and phosphorus levels 6, 2
- Assessment of calcium and phosphorus levels may be advisable during treatment 6
- Side effects are less common with nasal administration compared to injectable forms 7
- Calcitonin is contraindicated in patients with allergies to calcitonin-salmon or synthetic calcitonin-salmon 2
Prevention of Additional Fractures
- While calcitonin may provide pain relief, other agents such as ibandronate and strontium ranelate are recommended for preventing additional symptomatic fractures 1
- For long-term fracture prevention, bisphosphonates may be more cost-effective, as calcitonin is approximately eight times more expensive than alendronate 3
- BMD should be measured yearly while on calcitonin treatment to assess effectiveness 3
Special Considerations
- For compression fractures at L3 or L4 levels, referred abdominal pain may occur due to involvement of the L2 nerve root 1
- For persistent pain beyond 4 weeks, an L2 nerve root block may be considered as a treatment option 1
- Calcitonin should be used only in postmenopausal women with less severe osteoporosis who cannot tolerate other treatments 2
Common Pitfalls to Avoid
- Delaying initiation of calcitonin beyond 5 days after fracture onset may reduce its analgesic efficacy 2
- Using calcitonin as first-line therapy for long-term fracture prevention is not supported by current evidence 7
- Expecting significant pain relief with calcitonin for chronic pain from older fractures (>1 year) is not supported by evidence 5
- Failing to provide concurrent calcium and vitamin D supplementation may reduce overall treatment effectiveness 2