In my last post, I reviewed some data on the effectiveness of starting Vitamin D supplements after a patient sustains a fracture. The idea was that they might start building better bone and heal their fractures more readily if they boost their D levels. Unfortunately, this was not shown to be true.
Vitamin D improves bone health by facilitating absorption of calcium from the gut. This is a bit indirect and relies on sufficient intake of calcium and good hormonal regulation that directs osteoblasts to incorporate the mineral into bone. Why not work with those hormones directly to try to increase the amount of calcium that is deposited?
Calcitonin is a peptide hormone that has two major effects on calcium levels: it inhibits osteoclast activity that is breaking down bone and releasing calcium from it, and it inhibits calcium reabsorption in the kidneys which causes more to be excreted in the urine.
Perhaps giving calcitonin after sustaining a fracture might improve healing. Many orthopedic surgeons and neurosurgeons swear by this drug. Unfortunately, there are very few randomized, controlled studies of its use for this indication. A meta-analysis was performed that examined both utility and cost-effectiveness that I found interesting.
Here are the factoids:
- There was some mild evidence that nasal calcitonin was effective in preventing vertebral fractures
- One paper showed a benefit when giving 200 IU of intranasal salmon calcitonin daily over a 5 year period
- But a benefit was not shown if 100 or 400 IU were given (this is weird)
- A marker of bone turnover showed equal reduction in 200 and 400 IU groups (why isn’t this less in the 200 IU group?)
- Financial analysis showed that it was only marginally cost effective
- Current retail pricing is about $125 for a month supply
- Mild side effects like runny nose and nausea are common
- Intranasal calcitonin has been shown to reduce pain during healing of vertebral fractures
Bottom line: What does all of this mean? First, salmon calcitonin might decrease the number of future vertebral fractures. I say might because only the 200 IU dose in the study showed this effect. I can see where higher doses might be more effective to a point, but having only the middle dose show up as effective is just odd and makes me worry about the study.
The data does seem compelling that taking this product decreases pain during fracture healing. A meta-analysis of this showed that the effect probably only lasts up to a month.
And finally, from a cost-effectiveness standpoint for avoiding future fractures, this medication is marginal. Luckily, it is relatively cheap at $125 retail and about $25 with insurance in the US.
Wrapping it all up, intranasal salmon calcitonin might reduce fracture pain for a month and might decrease the likelihood of future vertebral fractures. However, the data are weak enough that cost-effectiveness is borderline. And there are more effective (and cheaper) analgesics available.
The absolute best way to strengthen bones is to exercise, especially engaging in weight-bearing activities. Not only does this strengthen bones, it also increases overall fitness and health. In general, medications are not the way to go to strengthen bones. It took decades for your patient to become osteoporotic. And while these drugs might improve their bone density slowly, a graduated and supervised exercise regimen is probably the best thing you can do for them.
- Efficacy of calcitonin for treating acute pain associated with osteoporotic vertebral compression fracture: an updated systematic review. CJEM 2020 May;22(3):359-367.
- A Randomized Trial of Nasal Spray Salmon Calcitonin in Postmenopausal Women with Established Osteoporosis: the Prevent Recurrence of Osteoporotic Fractures Study. PharmacoEconomics, 2001, Vol.19 (5), p.565-575.
- A randomized, double-blind, multicenter, placebo-controlled study to evaluate the efficacy and safety of oral salmon calcitonin in the treatment of osteoporosis in postmenopausal women taking calcium and vitamin D. Bone 2016 Oct;91:122-9.