What is the role of calcitonin (salmon calcitonin) in managing hip fracture pain?

Calcitonin for Hip Fracture Pain Management

Calcitonin is NOT recommended as a standard treatment for hip fracture pain, as the most recent and authoritative AAOS 2022 guidelines make no mention of calcitonin and instead strongly recommend multimodal analgesia incorporating preoperative nerve blocks as the primary pain management strategy. 1

Current Guideline-Based Pain Management for Hip Fractures

The American Academy of Orthopaedic Surgeons 2022 guidelines provide a strong recommendation for multimodal analgesia incorporating preoperative nerve blocks to treat pain after hip fracture. 1 This represents the evidence-based standard of care and should be followed unless a clear and compelling rationale exists for an alternative approach.

First-Line Analgesic Approach

• Regular acetaminophen (1000 mg IV or PO every 6 hours) should be administered as the cornerstone of pain management, with scheduled around-the-clock dosing preferred over as-needed administration. 2, 3
• Peripheral nerve blocks (femoral or fascia iliaca) should be placed at presentation to reduce both preoperative and postoperative opioid requirements. 1, 2, 3
• NSAIDs may be considered for severe pain, though they should be used with extreme caution in hip fracture patients and are relatively contraindicated in those with renal dysfunction (present in approximately 40% of hip fracture patients). 1, 2

Opioid Management

• Opioids should be reserved strictly for breakthrough pain when non-opioid strategies have failed, using the shortest duration and lowest effective dose. 3
• Opioids should be used with caution until renal function is assessed, with both dose and frequency reduced (e.g., halved) in patients with renal dysfunction. 1

Calcitonin: Limited and Outdated Evidence

While calcitonin has been studied for fracture-related pain, the evidence is weak and does not support its use in hip fractures specifically:

Evidence from Spinal Compression Fractures (Not Hip Fractures)

• The AAOS 2011 guideline for osteoporotic spinal compression fractures (not hip fractures) suggested calcitonin 200 IU for 4 weeks for acute injuries (0-5 days after onset), showing clinically important pain reduction at 1-4 weeks. 1
• This recommendation was based on Level II evidence from spinal fractures and cannot be extrapolated to hip fractures, which have different pain mechanisms and management priorities.

Limited Hip Fracture-Specific Data

• A 2002 randomized controlled trial of intranasal calcitonin 200 IU daily for 3 months in 260 hip fracture patients showed no statistically significant difference in pain at 3 months (median VAS 0 mm in calcitonin group vs 4 mm in placebo, P=0.15). 4
• The same study found no significant differences in mortality, side effects, length of hospital stay, or functional recovery. 4
• A 2005 open study in post-THA patients showed some benefit, but this was an uncontrolled study with significant methodological limitations. 5

FDA Labeling and Safety Concerns

• Calcitonin salmon nasal spray is FDA-approved only for postmenopausal osteoporosis treatment in women greater than 5 years postmenopause when alternative treatments are not suitable. 6
• Fracture reduction efficacy has not been demonstrated. 6
• Due to possible association between malignancy and calcitonin salmon use, the need for continued therapy should be re-evaluated periodically. 6

Critical Clinical Pitfalls

• Do not delay definitive surgical fixation while attempting medical pain management—early fracture fixation provides the most effective analgesia. 1
• Do not use calcitonin as a substitute for guideline-recommended multimodal analgesia with nerve blocks, as this represents a deviation from strong evidence-based recommendations. 1
• Systematically evaluate pain in all elderly patients, as 42% of patients over 70 receive inadequate analgesia despite reporting moderate to high pain levels. 3
• Both inadequate analgesia and excessive opioid use increase the risk of postoperative delirium in elderly patients. 3

Practical Algorithm for Hip Fracture Pain Management

1. Immediate (Emergency Department/Admission):

   • Acetaminophen 1000 mg IV/PO every 6 hours (scheduled) 2, 3
   • Femoral or fascia iliaca nerve block 1
   • Cautious opioid use only if needed for breakthrough pain 1, 3

2. Preoperative:

   • Continue scheduled acetaminophen 2, 3
   • Maintain nerve block or place preoperative block 1
   • Optimize fluid status and medical comorbidities 1

3. Postoperative:

   • Multimodal analgesia per AAOS strong recommendation 1
   • Continue scheduled acetaminophen 2, 3
   • Consider adjunctive gabapentinoids for neuropathic components 2, 3
   • Minimize opioid exposure 3

Calcitonin has no established role in this evidence-based algorithm for hip fracture pain management.