Calcitonin

Pronunciation

(kal si TOE nin)

U.S. Brand Names

Miacalcin®

Synonyms

Calcitonin (Salmon)

Generic Available

Canadian Brand Names

Calcimar®; Caltine®; Miacalcin® NS

Use

Calcitonin (salmon): Treatment of Paget's disease of bone (osteitis deformans); adjunctive therapy for hypercalcemia; used in postmenopausal osteoporosis and osteogenesis imperfecta

Pregnancy Risk Factor

Lactation

Excretion in breast milk unknown

Contraindications

Hypersensitivity to salmon protein or gelatin diluent

Warnings/Precautions

A skin test should be performed prior to initiating therapy of calcitonin salmon; have epinephrine immediately available for a possible hypersensitivity reaction

Adverse Reactions

>10%:

Cardiovascular: Facial flushing

Gastrointestinal: Nausea, diarrhea, anorexia

Local: Edema at injection site

1% to 10%:

Genitourinary: Polyuria

Neuromuscular & skeletal: Back/joint pain

Respiratory: Nasal bleeding/crusting (following intranasal administration)

<1% (Limited to important or life-threatening): Dyspnea

Overdosage/Toxicology

Symptoms of overdose include nausea, vomiting, hypocalcemia, and hypocalcemic tetany. Treat symptomatically.

Drug Interactions

Plicamycin may enhance hypocalcemic effect

Ethanol/Nutrition/Herb Interactions

Ethanol: Avoid ethanol (may increase risk of osteoporosis).

Stability

Salmon calcitonin: Injection: Store under refrigeration at 2°C to 6°C/36°F to 43°F; stable for up to 2 weeks at room temperature; NS has been recommended for the dilution to prepare a skin test

Salmon calcitonin: Nasal: Store unopened bottle under refrigeration at 2°C to 8°C; once the pump has been activated, store at room temperature

Mechanism of Action

Structurally similar to human calcitonin; it directly inhibits osteoclastic bone resorption; promotes the renal excretion of calcium, phosphate, sodium, magnesium and potassium by decreasing tubular reabsorption; increases the jejunal secretion of water, sodium, potassium, and chloride

Pharmacodynamics/Kinetics

Hypercalcemia:

Onset of action: ~2 hours

Duration: 6-8 hours

Distribution: Does not cross placenta

Half-life elimination: SubQ: 1.2 hours

Excretion: Urine (as inactive metabolites)

Dosage

Salmon calcitonin:

Children: Dosage not established

Adults:

Paget's disease: I.M., SubQ: Initial: 100 units/day; maintenance: 50 units/day or 50-100 units every 1-3 days

Hypercalcemia: Initial: I.M., SubQ: 4 units/kg every 12 hours; may increase up to 8 units/kg every 12 hours to a maximum of every 6 hours

Osteogenesis imperfecta: I.M., SubQ: 2 units/kg 3 times/week

Postmenopausal osteoporosis:

I.M., SubQ: 100 units/day

Intranasal: 200 units (1 spray)/day

Administration

I.M. route is preferred if volume exceeds 2 mL.

Monitoring Parameters

Serum electrolytes and calcium; alkaline phosphatase and 24-hour urine collection for hydroxyproline excretion (Paget's disease); serum calcium

Reference Range

Therapeutic: <19 pg/mL (SI: 19 ng/L) basal, depending on the assay

Dietary Considerations

Adequate vitamin D and calcium intake is essential for osteoporosis. Patients with Paget's disease and hypercalcemia should follow a low calcium diet as prescribed.

Patient Education

Inform prescriber of all prescriptions, OTC medications, or herbal products you are taking, and any allergies you have. Do not take any new medication during therapy unless approved by prescriber. If administered by injection, you or a significant other will be instructed on how to give the injections and dispose of syringes/needles (follow directions exactly). Keep drug vials in refrigerator; do not freeze. May cause increased warmth and flushing (this should only last about 1 hour after administration; taking drug in evening may minimize these discomforts). Report significant nasal irritation if using nasal spray. Immediately report twitching, muscle spasm, dark-colored urine, hives, significant skin rash, palpitations, or respiratory difficulty. Pregnancy/breast-feeding precautions: Inform prescriber if you are or intend to become pregnant. Consult prescriber if breast-feeding.

Dental Health: Effects on Dental Treatment

No significant effects or complications reported

Dental Health: Vasoconstrictor/Local Anesthetic Precautions

No information available to require special precautions

Mental Health: Effects on Mental Status

None reported

Mental Health: Effects on Psychiatric Treatment

None reported

Oncology: Emetic Potential

High (>50%); nausea and vomiting occur commonly with calcitonin, but are generally considered to be mild

Oncology: Vesicant

Dosage Forms

Injection, solution, calcitonin-salmon: 200 int. units/mL (2 mL)

Solution, nasal spray, calcitonin-salmon: 200 int. units/0.09 mL (3.7 mL) [contains benzalkonium chloride]

References

Bauwens SF, "Osteomalacia and Osteoporosis," Pharmacotherapy: A Pathophysiologic Approach , 2nd ed, DiPiro JT, Talbert RL, Hayes PE, et al, eds, New York, NY, 1992, 1293-1312.

Bergqvist E, Sjoberg HE, Hjern B, et al, "Calcitonin in the Treatment of Hypercalcaemic Crisis," Acta Med Scand , 1972, 192(5):385-9.

Lyritis GP, Tsakalakos N, Magiasis B, et al, "Analgesic Effect of Salmon Calcitonin in Osteoporotic Vertebral Fractures: A Double-Blind, Placebo-Controlled Clinical Study," Calcif Tissue Int , 1991, 49(6):369-72.

Pontiroli AE, Pajetta E, Scaglia L, et al, "Analgesic Effect of Intranasal and Intramuscular Salmon Calcitonin in Postmenopausal Osteoporosis: A Double-Blind, Double-Placebo Study," Aging , 1994, 6(6):459-63.

Reginster JY, Deroisy R, Lecart MP, et al, "A Double-Blind, Placebo-Controlled, Dose-Finding Trial of Intermittent Nasal Salmon Calcitonin for Prevention of Postmenopausal Lumbar Spine Bone Loss," Am J Med , 1995, 98(5):452-8.

Reginster JY, "Calcitonin for Prevention and Treatment of Osteoporosis," Am J Med , 1993, 95(5A):44S-47S.

Stevenson JC, "Current Management of Malignant Hypercalcemia," Drugs , 1988, 36(2):229-30.

International Brand Names

Acticalcin® (BR); Anguilce® (AR); Azucalcit® [salmon] (DE); Biocalcin® [salmon] (IT); Biostin® (HU); Cadens® [salmon] (FR); Calcihexal® [salmon] (DE, PL); Calcimar® (CA); Calcioton® [salmon] (IT); Calcitonina Almirall® [salmon] (ES); Calcitonina Armour® [salmon] (IT); Calcitonina Hubber® [salmon] (ES); Calcitonina Hubber® (RO, TR, YU); Calcitonina Sandoz® [salmon] (AR, IT); Calcitonin AZU® [salmon] (DE); Calcitonine Pharmy II® [salmon] (FR); Calcitonin Novartis® (AT); Calcitonin® [salmon] (PL); Calcitonin-ratiopharm® [salmon] (DE); Calcitonin Rotexmedica® [salmon] (DE); Calcitonin Sandoz® [salmon] (DE); Calcitonin Stada® [salmon] (DE); Calcitonin von ct® [salmon] (DE); Calcitoran® (JP); Calco® [salmon] (HU, IT, SG, TH); Calfosina® [salmon] (CL); Calnisan® [salmon] (CL); Calogen® [salmon] (ES, PT); Calsynar® [salmon] (AR, BE, BR, CZ); Calsynar® (DE); Calsynar® [salmon] (ES, GB, HK, IE, IN, LU, PL, TR); Calsynar Nasal® [salmon] (CL); Calsyn® [salmon] (FR, PT); Caltine® (CA); Casalm® [salmon] (AT); Catonin® [salmon] (IT); Cibacalcina® [human] (ES); Cibacalcin® [human] (AT, DE, IL, MT, RO); Cibacalcine® [human] (FR, LU); Citonina® (AR); Forcaltonin® [salmon] (GB); Greves® [salmon] (AR); Kalsimin® [salmon] (ES); Karil® [salmon] (DE, LU); Menocal® [salmon] (SG); Miacalcic® [salmon] (AT, AU, BE, BG, BR, CH, CL, CO, CR, CZ, DK, DO, EC, ES, FI, FR, GB, GT, HK, HN, HR, HU, ID, IL, MT, MX, NO, NZ, PA, PL, PT, RO, RU, SE, SG, SI, SV, TH, TR, YU, ZA); Miacalcin® NS (CA); Miadenil® [salmon] (IT, RO); Nylex® (RO); Oseototal® [salmon] (ES); Oseum® [salmon] (MX); Osmil® [salmon] (AR); Ospor® [salmon] (ES); Osseocalcina® (PT); Osteobion® [salmon] (ES); Osteocalcin® [salmon] (IT); Osteociton® (CL); Osteodon® [salmon] (CZ); Osteos® [salmon] (DE); Osteostabil® [salmon] (DE); Osteovis® [salmon] (IT); Ostostabil® [salmon] (DE, PL); Salcat® [salmon] (PT); Salco® [salmon] (IL); Salmocalcin® (AR, TR); Salmofar® [salmon] (IT); Sical® [salmon] (ES); Steocalcin® [salmon] (BE); Tonocalcin® [salmon] (CZ, ID, MX, PL, RO, TH, TR); Tonocaltin® [salmon] (ES); Ucecal® [salmon] (AT, ES, LU, TR); Zycalcit® (IN)

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