Calcitonin Dosing for Hypercalcemia
For hypercalcemia management, start calcitonin-salmon at 4 International Units/kg body weight every 12 hours by subcutaneous or intramuscular injection, escalating to 8 IU/kg every 12 hours if response is inadequate after 1-2 days, with a maximum dose of 8 IU/kg every 6 hours. 1
Initial Dosing Strategy
- Begin with 4 IU/kg every 12 hours subcutaneously or intramuscularly as the FDA-approved starting dose for early treatment of hypercalcemic emergencies 1
- Calcitonin provides rapid calcium reduction within the first 12-24 hours, making it valuable as a bridge therapy until bisphosphonates take effect 2, 3
Dose Escalation Protocol
If serum calcium response is unsatisfactory after 1-2 days:
- Increase to 8 IU/kg every 12 hours 1
- If still inadequate after 2 additional days, escalate to maximum dose of 8 IU/kg every 6 hours 1
Clinical Context and Combination Therapy
Calcitonin should not be used as monotherapy for hypercalcemia. The drug works synergistically with bisphosphonates and should be combined with:
- IV hydration with normal saline as the foundational treatment 2, 4
- Bisphosphonates (zoledronic acid 4 mg IV preferred) for sustained calcium control 2
- Calcitonin bridges the gap during the 2-4 day delay before bisphosphonates achieve full effect 5, 6
Pediatric Considerations
In children with malignancy-related hypercalcemia:
- Use 8 IU/kg/dose, 4 times daily when standard adult dosing proves insufficient 5
- This higher frequency dosing (every 6 hours) has demonstrated effectiveness in severe pediatric cases where standard dosing failed 5
Important Limitations and Caveats
Tachyphylaxis develops rapidly with calcitonin, typically within 48-72 hours, limiting its utility to short-term management 6, 7
- Calcitonin is reserved for patients requiring rapid calcium reduction while awaiting bisphosphonate effect 2
- The drug should only be used in patients who cannot tolerate other treatments or as temporary bridge therapy 8, 2
- Screen for calcitonin-salmon hypersensitivity before administration, as anaphylaxis with death has been reported 1
- Monitor for hypocalcemia, particularly when combining with bisphosphonates 1
Alternative Formulations (Not for Hypercalcemia)
The nasal spray formulation (200 IU daily) and lower-dose injectable regimen (100 IU subcutaneously/intramuscularly every other day) are only indicated for osteoporosis and Paget's disease, not for hypercalcemia management 8, 1