CalcitoninRx

Trade Names
Nasal spray: Miacalcin (salmon)
Injection: Miacalcin (calcitonin salmon injection)

Synonyms: Salmon calcitonin

Drug Class: Hormone

Preparations
Salmon calcitonin nasal spray 2 mL bottle, 200 IU/spray
Salmon calcitonin injection 2 mL multidose vial, 200 IU/ml

Dose: Salmon calcitonin nasal: For osteoporosis one spray (200 IU) daily; use alternate nostrils
Salmon calcitonin injection for Paget’s disease 100 IU by subQ injection daily

Indications
Nasal calcitonin: Osteoporosis when alternative agents not suitable
Calcitonin injection: Paget’s disease when alternative agents not suitable

Mechanism of Action: Calcitonin inhibits osteoclastic bone resorption and promotes renal excretion of calcium.

Contraindications: Hypersensitivity to salmon protein or salmon calcitonin

Precautions: Skin testing should be considered for patients with suspected sensitivity. A meta-analysis of clinical trials with calcitonin-salmon (nasal spray and investigational oral forms) suggested an increased risk of malignancies (4.1 percent) compared with placebo-treated patients (2.9 percent). The data were not sufficient for further analyses by specific type of malignancy.

Monitoring: Consider monitoring of bone density. Consider periodic nasal examination for nasal preparation.

Pregnancy Risk: C

Adverse Effects
Common: Rhinitis and nasal irritation, flushing, headache, nausea, diarrhea, injection site reaction
Less common: Hypocalcemia, malignancy, antibodies to salmon-calcitonin, anaphylaxis

Drug Interactions: None of significance

Patient Instructions: Teach the patient the injection technique. For nasal spray, use alternate nostrils. Discontinue if nasal ulceration or bleeding occurs.

Comments: Antibody formation occurs and 5%–10% of patients may become resistant to treatment after long-term use. In contrast to bisphophonates, a decrease in both vertebral and hip fracture rate is not well established with calcitonin. Thus, bisphosphonates are the preferred drugs for osteoporosis. Similarly, bisphosphonates have largely replaced calcitonin in Paget’s disease. Adequate calcium (1,000–1,500 mg elemental calcium/day) and vitamin D (400 IU/day) intake is recommended when using calcitonin.

Clinical Pharmacology: Short half-life (1–2 hours), rapid metabolism by kidneys. Absorption of nasal spray is poor (10%–25%).

Cost: $$$

BIBLIOGRAPHY

Ralston SH. Clinical practice. Paget's disease of bone. N Engl J Med 2013;368:644-50.PMID: 23406029