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Class: Antiparathyroid Agents
- Bone Resorption Inhibitors
VA Class: HS900
CAS Number: 47931-85-1
Brands: Fortical, Miacalcin

Medically reviewed by Last updated on March 16, 2021.


Polypeptide hormone secreted by parafollicular cells (C cells) of thyroid gland; acts predominantly on bone to lower serum calcium concentration and inhibit bone resorption.125

Uses for Calcitonin

Paget Disease of Bone

Treatment of Paget disease of bone.125 Consider treatment with calcitonin or a bisphosphonate (e.g., alendronate, etidronate, pamidronate, risedronate) in patients with biochemical markers suggestive of an increase in bone remodeling, those who are symptomatic, and those at risk for future complications from their disease (e.g., those with pagetic lesions in weight-bearing regions or adjacent to joints).143


Early treatment of hypercalcemic emergencies (with other appropriate agents) when a rapid decrease in serum calcium concentration is required.125

Postmenopausal Osteoporosis

Treatment of postmenopausal osteoporosis in women >5 years postmenopause.125 127 145

In addition to adequate intake of calcium/vitamin D and other lifestyle modifications (e.g., exercise, avoidance of excessive alcohol and tobacco use), experts recommend that pharmacologic therapy for osteoporosis be considered in postmenopausal women with high risk of fractures (generally those who have experienced a previous hip or vertebral fracture or who have low BMD); pharmacologic therapy also may be considered in postmenopausal women with low bone mass, although there is less evidence supporting overall fracture risk reduction in such patients.147 148

Use of a drug with proven antifracture efficacy is recommended; experts generally recommend calcitonin as a last-line therapy when other drugs are not effective or tolerated.147 148

Individualize choice of therapy based on potential benefits (with respect to fracture risk reduction) and adverse effects of therapy, patient preferences, comorbidities, and risk factors.147 148

Glucocorticoid-induced Osteoporosis

Has been used in the treatment of glucocorticoid-induced osteoporosis; however, other therapies (e.g., oral bisphosphonates) are preferred.126 622

Calcitonin Dosage and Administration


Paget Disease of Bone

  • Monitor by periodic determinations of serum alkaline phosphatase and urinary hydroxyproline excretion as well as evaluation of symptoms.125

  • Investigate possibility of antibody formation in any patient who shows initial response but subsequently relapses.125

Postmenopausal Osteoporosis


Administer by sub-Q or IM injection (Paget disease of bone, hypercalcemia, postmenopausal osteoporosis)125 or intranasally (postmenopausal osteoporosis).127 145

IM Administration

IM injection preferred when injection volume >2 mL.125

Use multiple sites of injection when volume >2 mL.125

Sub-Q Administration

Sub-Q injection preferred for patient self-administration.125

Intranasal Administration

Administer once daily (as a single spray in 1 nostril) using metered-dose spray pump supplied by manufacturer.127 145 Alternate nostrils daily.127 145

Allow solution to reach room temperature before priming pump and administering first dose.127 145

Prime pump before first dose; do not prime before each dose.127 145

Miacalcin: To prime pump, hold bottle upright and depress the 2 white side arms of pump toward the bottle until full spray is produced.127

Fortical: To prime pump, hold bottle upright and depress the 2 white side arms of pump toward the bottle at least 5 times until full spray is produced.145

Administer dose by placing nozzle in nostril with head in upright position and firmly depressing pump toward bottle.127 145

Discard spray pump after 30 actuations, since the correct drug dose per actuation cannot be assured if used for additional doses.127


Activity of calcitonin salmon expressed in terms of International Units (units).125 127 145

Intranasal spray pumps deliver 0.09 mL of solution per actuation; each 0.09-mL spray delivers 200-unit dose.127 145


Paget Disease of Bone
Sub-Q or IM

Initial dosage: 100 units (0.5 mL) daily.125

Maintenance: 50 units (0.25 mL) daily or every other day; higher dosage (100 units daily) appropriate in patients with serious deformity or neurologic involvement.125

Dosage >100 units daily usually does not produce an improved response in patients who relapse while receiving calcitonin.101 105 109 110 111 112 125

Sub-Q or IM

Initially, 4 units/kg every 12 hours; may increase dosage after 1 or 2 days (if response not adequate) to 8 units/kg every 12 hours; may further increase dosage after 2 days (if response not adequate) to 8 units/kg every 6 hours.125

Postmenopausal Osteoporosis
Sub-Q or IM

Minimum effective dosage not established; 100 units every other day may be effective in preserving vertebral BMD.125


200 units (1 spray) daily.127 145

Prescribing Limits


Sub-Q or IM

Maximum 8 units/kg every 6 hours.125

Cautions for Calcitonin


  • Known hypersensitivity to calcitonin salmon.125 127 145


Sensitivity Reactions

Serious allergic reactions (bronchospasm, swelling of tongue or throat, anaphylactic shock, at least 1 death due to anaphylaxis) reported in patients receiving calcitonin injection.125 127 145 Differentiate hypersensitivity reactions from generalized flushing and hypotension.125

Allergic-type reactions also reported in patients receiving calcitonin nasal spray.127 145

Appropriate agents for treatment of hypersensitivity reactions should be readily available.125 127 145

For patients with suspected sensitivity to calcitonin, consider skin testing prior to initiating therapy.125 127 145

General Precautions

Hypocalcemic Tetany

Possibility of hypocalcemic tetany following parenteral administration;8 111 125 have calcium injection readily available, particularly during first several doses of parenteral calcitonin.125

Laboratory Monitoring

Coarse granular casts and casts containing renal tubular epithelial cells reported in some young adult volunteers at bedrest who received parenteral calcitonin in a study of its effect on immobilization osteoporosis.34 125 Clcr not altered and proteinuria not reported; urine sediment returned to normal within 4 days following drug discontinuance.34 125 Effect not reported by other investigators.125 127

Periodic examinations of urine sediment are recommended in patients receiving long-term parenteral therapy.34 125 145

Radiographic Monitoring

In patients with Paget disease, carefully evaluate radiographic evidence of marked progression of pagetic lesions to rule out osteogenic sarcoma (since frequency is increased in patients with Paget disease).125

Nasal Examinations

Periodic nasal examinations with visualization of nasal mucosa, turbinates, septum, and mucosal blood vessel status are recommended for patients receiving calcitonin nasal spray.127 145

Discontinue nasal spray if severe ulceration of nasal mucosa (i.e., ulcers >1.5 mm in diameter or penetrating below the mucosa, ulcers associated with heavy bleeding) occurs.127 145 For smaller ulcers, interrupt therapy until healing occurs.127 145

Specific Populations


Category C.125 127 145


Inhibits lactation in animals.125 127 145 Not known whether calcitonin is distributed into human milk.125 127 145 Use not recommended.125 127 145

Pediatric Use

Experience with calcitonin in children with juvenile Paget disease is very limited; the relationship between this disorder and adult Paget disease is not established.125

Experience with calcitonin in children with idiopathic juvenile osteoporosis is very limited; the relationship between this disorder and postmenopausal osteoporosis is not established.127 145

Data are inadequate to support use of calcitonin in children.125 127 145

Geriatric Use

Adverse nasal effects (i.e., rhinitis, irritation, congestion) reported more frequently in patients >65 years of age receiving calcitonin nasal spray.127 145 Nasal effects described as mild.127 145

Common Adverse Effects

With parenteral therapy, nausea,125 118 vomiting,118 125 injection site reaction,125 flushing of the face, ears, hands, and feet.24 100 102 104 106 107 117 118 120 125

With intranasal therapy, rhinitis, nasal symptoms, back pain.127 145

Interactions for Calcitonin


Possible reduced antiresorptive response to calcitonin in patients with Paget disease previously treated with bisphosphonates.127 145

Calcitonin Pharmacokinetics



Destroyed in GI tract; administer parenterally or intranasally.125 127 145

Rapidly absorbed by nasal mucosa; bioavailability of intranasal dose relative to IM dose is approximately 3%.127 145


With IM or sub-Q administration, 15 minutes.c

Reduction in serum calcium concentration in patients with hypercalcemia evident within about 2 hours after first injection.125

Clinical and/or biochemical effects in Paget disease may not be evident for several months.125


With IM or sub-Q administration, 8–24 hours.c

Reduction in serum calcium concentration in patients with hypercalcemia persists for about 6–8 hours after single injection.125



Not studied extensively.125 127 145

Apparently does not cross placenta.125 127 145



Appears to be rapidly metabolized to smaller inactive fragments in kidney, blood, and peripheral tissues.125

Elimination Route

Excreted in urine as metabolites.125


<1 hour.114 127







Nasal Solution

Miacalcin and Fortical new unassembled bottles: 2–8°C; protect from freezing.127 145

Miacalcinbottle in use: 15–30°C, in upright position for up to 35 days.127

Fortical bottle in use: 20–25°C, in upright position for up to 30 days.145

Actions and Spectrum

  • Commercially available as calcitonin salmon.125 127 145 Prepared synthetically or using recombinant DNA technology; contains the 32 amino acids in the same linear sequence as occurs in natural calcitonin of salmon origin.125 127 145 Calcitonin salmon prepared by recombinant DNA technology is structurally identical to calcitonin salmon produced by chemical synthesis.145

  • Calcitonin salmon has same pharmacologic activity as calcitonin human, but calcitonin salmon is more potent and has longer duration of action.100 101 102 103 104 109 112 114 125 127 145

  • Acts predominantly on bone to lower serum calcium concentration;125 127 145 also has direct effects on kidneys and GI tract.125

  • Directly inhibits osteoclastic bone resorption, altering the function and/or number of osteoclasts.125 127 145

  • In most patients with Paget disease, causes a decrease in the rate of bone turnover with a resultant decrease in elevated serum alkaline phosphatase concentrations and urinary hydroxyproline excretion.125 These changes appear to correspond to changes toward more normal bone formation.125

Advice to Patients

  • If patient or caregiver is to administer parenteral calcitonin, provide careful instructions on proper administration methods, including aseptic technique.125

  • For patients using calcitonin nasal spray, provide careful instruction on storage, pump assembly, priming of pump, and administration.127 145 Advise patients to record number of doses used and to discard the bottle after 30 doses.127

  • Advise patients using calcitonin nasal spray to notify their clinician if nasal irritation develops.127 145

  • Importance of women informing clinicians if they are or plan to become pregnant or to breast-feed.125 127 145

  • Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs as well as any concomitant illnesses.125 127 145

  • Importance of informing patients of other important precautionary information.125 127 145 (See Cautions.)


Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Calcitonin (Salmon)


Dosage Forms


Brand Names




200 units/metered spray

Miacalcin (synthetic)


Fortical (recombinant DNA origin)




200 units/mL*

Miacalcin (synthetic; with phenol 5 mg/mL)


AHFS DI Essentials™. © Copyright 2021, Selected Revisions March 26, 2018. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.

† Use is not currently included in the labeling approved by the US Food and Drug Administration.


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