Calcitonin Dosage for Hypercalcemia and Osteoporosis
Recommended Dosing
For postmenopausal osteoporosis, use calcitonin-salmon nasal spray 200 IU once daily, alternating nostrils each day, as this is the only dose proven to reduce vertebral fractures. 1
Osteoporosis Treatment
- Nasal spray (preferred route): 200 IU intranasally once daily, alternating nostrils 1
- Subcutaneous/intramuscular: 100 IU every other day for less urgent situations 2
- The 200 IU nasal dose reduced vertebral fracture risk by 33% (RR 0.67,95% CI 0.47-0.97) in the landmark PROOF study, while 100 IU and 400 IU doses failed to show statistically significant fracture reduction 3, 4
- Critical pitfall: Higher doses (400 IU) and lower doses (100 IU) are NOT more effective—stick with 200 IU daily 4
Hypercalcemia Treatment
- Standard dosing: Calcitonin-salmon 100 IU subcutaneously or intramuscularly every other day 2
- Alternative: 200 IU per day as nasal spray 2
- Calcitonin provides rapid onset within 2-4 hours but has limited efficacy and should be used primarily as a bridge until bisphosphonates take effect 2, 5
- Peak effect occurs at 24-48 hours with duration of action 4-7 days before "escape phenomenon" develops 5
Administration Guidelines
Nasal Spray Technique
- Prime pump only once when first opening bottle by depressing side arms until full spray produced 1
- Do not reprime before each daily dose—this wastes medication 1
- Alternate nostrils daily (left nostril day 1, right nostril day 2, etc.) 1
- Store at room temperature (20-25°C) after opening; discard after 35 days at room temperature 1
- Bottle contains at least 30 doses 1
Injectable Administration
- For subcutaneous or intramuscular routes, administer 100 IU every other day 2
- Check for allergy to calcitonin-salmon before first dose (absolute contraindication) 2
Clinical Context and Limitations
When to Use Calcitonin
- Osteoporosis: Consider as alternative when bisphosphonates, SERMs, or estrogen are contraindicated or poorly tolerated 6
- Hypercalcemia: Use primarily in patients who cannot tolerate other treatments or as temporary bridge therapy 2
- Calcitonin is NOT first-line for hypercalcemia—bisphosphonates (zoledronic acid 4 mg IV preferred) remain the cornerstone treatment 2
Important Caveats
- Calcitonin provides only modest BMD increases (1-3.3% at lumbar spine after 1 year) compared to other osteoporosis therapies 4
- The "escape phenomenon" limits long-term efficacy in hypercalcemia, with effectiveness diminishing after 4-7 days despite continued dosing 5
- No consistent effect demonstrated on cortical bone or hip fracture risk 4
- Calcitonin has analgesic properties for bone pain from vertebral fractures or metastases, which may provide additional clinical benefit 6, 5
Monitoring
- Monitor lumbar vertebral bone mass periodically in osteoporosis patients to document stabilization or increases in bone density 1
- Biochemical markers of bone turnover are NOT reliable for monitoring calcitonin response and should not be used solely to determine clinical response 1
- In hypercalcemia, monitor serum calcium and renal function regularly 2