Medically reviewed on September 10, 2018
(kal si TOE nin)
- Calcitonin (Salmon)
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Miacalcin: 200 units/mL (2 mL) [contains phenol]
Fortical: 200 units/actuation (3.7 mL [DSC])
Miacalcin: 200 units/actuation (3.7 mL [DSC])
Generic: 200 units/actuation (3.7 mL)
Brand Names: U.S.
- Fortical [DSC]
Peptide sequence similar to human calcitonin; functionally antagonizes the effects of parathyroid hormone. 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
Intranasal: Rapidly but highly variable and lower than IM administration
Vd: 0.15 to 0.3 L/kg
Metabolized in kidneys, blood and peripheral tissue
Urine (as inactive metabolites); Clearance: Salmon calcitonin: 3.1 mL/kg/minute
Onset of Action
Hypercalcemia: IM, SubQ: ~2 hours
Paget's disease: Within a few months; may take up to 1 year for neurologic symptom improvement
Time to Peak
Plasma: SubQ ~23 minutes; Nasal: ~10 to 13 minutes
Duration of Action
Hypercalcemia: IM, SubQ: 6 to 8 hours; following multiple doses, hypercalcemic effect diminishes within 24 to 48 hours (Nilsson 1978; Stevenson 1988)
Terminal: IM 58 minutes; SubQ 59 to 64 minutes; Nasal: ~18 to 23 minutes
Use: Labeled Indications
Hypercalcemia (injection): Adjunctive therapy for hypercalcemia. May be used in hypercalcemic emergencies when a rapid decrease in serum calcium is required or until more specific treatment of underlying disease is accomplished.
Paget disease (injection): Treatment of symptomatic Paget disease of bone (osteitis deformans) in patients who are nonresponsive or intolerant to alternative therapy
Postmenopausal osteoporosis (intranasal or injection): Treatment of osteoporosis in women more than 5 years postmenopause. Note: Due to limited comparative efficacy with other therapies, calcitonin is not a preferred agent for long-term therapy; however, short-term treatment may provide analgesic effect in patients with acute painful vertebral fractures (AACE/ACE [Camacho 2016]).
Hypersensitivity to calcitonin salmon or any component of the formulation
Note: Daily supplementation of calcium and vitamin D is recommended during calcitonin therapy for osteoporosis or Paget disease.
Paget disease, symptomatic: IM, SubQ: 100 units daily. Lower maintenance dosages (eg, 50 units 3 times/week) may be sufficient (DeRose 1974)
Hypercalcemia: Initial: IM, SubQ: 4 units/kg every 12 hours; if response is unsatisfactory after 24 to 48 hours, may increase to 8 units/kg every 12 hours; if response remains unsatisfactory after an additional 48 hours, may increase to a maximum dose of 8 units/kg every 6 hours. Hypocalcemic effect of calcitonin diminishes after 24 to 48 hours (Bilezikian 1993; Nilsson 1978; Stevenson 1988)
Postmenopausal osteoporosis: Calcitonin is not a preferred antiresorptive agent; however, short-term treatment may provide analgesic effect in patients with acute painful vertebral fractures (AACE/ACE [Camacho 2016]).
IM, SubQ: 100 units daily
Intranasal: 200 units (1 spray) in one nostril once daily
Refer to adult dosing.
Dosing: Renal Impairment
There are no dosage adjustments provided in the manufacturer's labeling.
Dosing: Hepatic Impairment
There are no dosage adjustments provided in the manufacturer's labeling.
Injection: NS has been recommended for the dilution to prepare a skin test in patients with suspected sensitivity.
Injection: May be administered IM or SubQ. IM route is preferred if the injection volume is >2 mL (use multiple injection sites if dose volume is >2 mL). SubQ route is preferred for outpatient self-administration unless the injection volume is >2 mL.
Nasal spray: Before first use, allow bottle to reach room temperature, then prime pump by releasing until a full spray is produced. To administer, place nozzle into nostril with head in upright position. Alternate nostrils daily. Do not prime pump before each daily use. Discard after 30 doses.
Patients with Paget's disease and hypercalcemia should follow a low calcium diet as prescribed. Recommended amounts of vitamin D and calcium intake is essential for preventing/treating osteoporosis. If dietary intake is inadequate, dietary supplementation is recommended. Women and men should consume:
Calcium: 1,000 mg/day (men: 50 to 70 years) or 1,200 mg/day (women ≥51 years and men ≥71 years) (IOM, 2011; NOF [Cosman 2014])
Vitamin D: 800 to 1,000 units/day (men and women ≥50 years) (NOF [Cosman, 2014]). Recommended Dietary Allowance (RDA): 600 units/day (men and women ≤70 years) or 800 units/day (men and women ≥71 years) (IOM, 2011).
Injection: Store under refrigeration at 2°C to 8°C (36°F to 46°F); protect from freezing. The following stability information has also been reported: May be stored at room temperature for up to 14 days (Cohen, 2007).
Nasal: Store unopened bottle under refrigeration at 2°C to 8°C (36°F to 46°F); do not freeze.
Fortical: After opening, store for up to 30 days at 20˚C to 25˚C (68˚F to 77˚F); excursions permitted to 15°C to 30°C (59°F to 86°F). Store in upright position.
Miacalcin: After opening, store for up to 35 days at room temperature of 15°C to 30°C (59°F to 86°F). Store in upright position.
Lithium: Calcitonin may decrease the serum concentration of Lithium. Monitor therapy
Zoledronic Acid: Calcitonin may enhance the hypocalcemic effect of Zoledronic Acid. Monitor therapy
Unless otherwise noted, frequencies reported are with nasal spray.
>10%: Respiratory: Rhinitis (<12%, including ulcerative)
1% to 10%:
Cardiovascular: Flushing (injection: 2% to 5%, hands or face; nasal spray: <1%)
Central nervous system: Depression (1% to 3%), dizziness (1% to 3%), paresthesia (1% to 3%)
Dermatologic: Erythematous rash (1% to 3%)
Gastrointestinal: Nausea (injection: 10%; nasal spray: 1% to 3%), abdominal pain (1% to 3%)
Hematologic & oncologic: Malignant neoplasm (5%), lymphadenopathy (1% to 3%)
Infection: Infection (1% to 3%)
Local: Injection site reaction (injection: 10%)
Neuromuscular & skeletal: Back pain (5%), myalgia (1% to 3%), osteoarthritis (1% to 3%)
Ophthalmic: Abnormal lacrimation (1% to 3%), conjunctivitis (1% to 3%)
Respiratory: Bronchospasm (1% to 3%), flu-like symptoms (1% to 3%), sinusitis (1% to 3%), upper respiratory tract infection (1% to 3%)
<1%, postmarketing, and/or case reports (all routes): Alopecia, altered sense of smell, anaphylactic shock, anaphylactoid reaction, anaphylaxis, anorexia, antibody development (drug efficacy can be affected), arthralgia, casts in urine, cough, decreased appetite (injection), diaphoresis, diarrhea, dysgeusia, dyspnea, earlobe pruritus (injection), edema, excoriation (nasal mucosa), eye pain, facial edema, fever, headache, hearing loss, hypersensitivity reaction, hypertension, hypocalcemia, musculoskeletal pain, nasal mucosa ulcer, nocturia, pedal edema, peripheral edema, polyuria, pruritus, salty taste (injection), skin rash, sneezing, tachycardia, tinnitus, tremor, urine abnormality, urticaria (injection), visual disturbance, vomiting
Concerns related to adverse effects:
• Hypersensitivity reactions: Salmon-derived products: Anaphylactic shock, anaphylaxis, bronchospasm, and swelling of the tongue or throat have been reported; have epinephrine immediately available for a possible hypersensitivity reaction. A skin test should be performed prior to initiating therapy of calcitonin salmon in patients with suspected sensitivity; a detailed skin testing protocol is available from the manufacturer.
• Hypocalcemia: Hypocalcemia with tetany and seizure activity has been reported. Hypocalcemia and other disorders affecting mineral metabolism (eg, vitamin D deficiency) should be corrected before initiating therapy; monitor serum calcium and symptoms of hypocalcemia during therapy. Administer in conjunction with calcium and vitamin D when treating Paget disease or postmenopausal osteoporosis.
• Malignancy: Analyses of randomized controlled trials (in osteoporosis and osteoarthritis) using the nasal spray and oral formulations have demonstrated a statistically significant increase in the risk of the development of cancer in calcitonin-treated patients (compared to placebo). The risk for malignancies is associated with long-term use of calcitonin (trials ranged from 6 months to 5 years in duration). Periodically reassess continued use of calcitonin therapy, carefully considering the risks versus benefits. Similar risk for other routes (subcutaneous, IM, IV) cannot be ruled out.
• Urinary sediment abnormalities: Coarse granular casts and casts containing renal tubular epithelial cells were observed following use in young adults on bed rest during a study to examine the effect of immobilization on osteoporosis; no other renal abnormalities were reported and sediment normalized after discontinuation; consider monitoring urine sediment periodically; however, the clinical significance of this finding is unknown.
• Osteoporosis: Risk vs benefit: Fracture reduction efficacy has not been demonstrated; use has not been shown to increase spinal bone mineral density in early postmenopausal women. Use should be reserved for postmenopausal women for whom alternative treatments are not suitable (eg, patients for whom other therapies are contraindicated or for patients who are intolerant or unwilling to use other therapies). Consider potential benefits of therapy against risks, including the potential risk for malignancy with long-term use. Short-term treatment may provide analgesic effect in patients with acute painful vertebral fractures (AACE/ACE [Camacho 2016]).
Dosage form specific issues:
• Nasal spray: Rhinitis and epistaxis have been reported; mucosal alterations may occur. Perform nasal examinations with visualization of the nasal mucosa, turbinates, septum and mucosal blood vessels prior to initiation of therapy, periodically during therapy, and at any time nasal symptoms occur. Temporarily withdraw use if ulceration of nasal mucosa occurs. Discontinue for severe ulcerations >1.5 mm, those that penetrate below the mucosa, or those associated with heavy bleeding. Patients >65 years of age may experience a higher incidence of nasal adverse events with calcitonin nasal spray.
• Antibody formation: Antibody formation to calcitonin-salmon has been reported with the injection and nasal spray. Consider the possibility of antibody formation in patients who initially respond to therapy but later do not respond to treatment.
Osteoporosis: Bone mineral density (BMD) should be evaluated 1 to 2 years after initiating therapy and every 1 to 2 years (or less frequently if stable) thereafter (AACE/ACE [Camacho 2016]; NOF [Cosman, 2014]); annual measurements of height and weight, assessment of chronic back pain; serum calcium and 25(OH)D; consider measuring biochemical markers of bone turnover
Paget disease: Alkaline phosphatase; pain; serum calcium and 25(OH)D
Nasal formulation: Visualization of nasal mucosa, turbinate, septum, and mucosal blood vessels (at baseline and with nasal complaints)
Consider periodic examinations of urine sediment
Endogenous calcitonin does not cross the placenta (Dochez 2015). Information related to the use of calcitonin in pregnancy is limited (Koren 2018; Krysiak 2011; Richa 2018; Turek 2012).
• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)
• Patient may experience rhinorrhea, headache, back pain, muscle pain, flushing, nausea, or vomiting. Have patient report immediately to prescriber signs of low calcium (muscle cramps or spasms, numbness and tingling, or seizures), severe rhinitis, nasal sores, nosebleed, or severe injection site irritation (HCAHPS).
• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.
Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for health care professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience, and judgment in diagnosing, treating, and advising patients.
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- Drug class: calcitonin