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Acute Pain | Chronic Pain | General

Calcitonin for pain relief following acute osteoporotic vertebral fractures

Clinical bottom line:

It is likely that calcitonin given subcutaneously or nasally is associated with pain relief in patients following acute osteoporotic vertebral fractures. However, original trials need to be revisited to determine whether this benefit is of statistical and clinical relevance. Further research is required to compare the efficacy of calcitonin with standard analgesics.


Vertebral fractures are the most common complication of osteoporosis, and occur approximately a decade earlier in life than hip fractures. Lifetime risk is estimated at 32% for women, and fractures can often cause acute onset of spinal pain on movement. Pain may persist for several months, is often localised to the affected vertebral level and is associated with percussion tenderness, notable disability and immobility. Although traditionally treated with standard analgesics, it has been noted that calcitonin relieves pain associated with this type of fracture. Calcitonin is a 32-amino-acid hormone which changes bone metabolism by inhibition of osteoclastic bone resorption, and is therefore used to treat the fracture.

Systematic review

Maksymowych, W. P. Managing acute osteoporotic vertebral fractures with calcitonin. Canadian Family Physician. 1998; 44:2160-2166.

Date review completed: pre-1998

Number of trials included: 9

Number of patients:

Control group: placebo or active

Main outcomes: pain

Inclusion criteria were double-blind, randomised, controlled trials of calcitonin for pain relief in patients with acute vertebral fractures; nasal or subcutaneous administration.

Searching was limited to MEDLINE. Reviewers provided a descriptive summary of included trials. We have only included information on pain relief from trials, which reported on placebo comparisons, rather than changes from baseline. However, it is not explicit in the review whether reported group differences were statistical differences. It is not therefore possible to determine the efficacy of calcitonin without revisiting the original trials to confirm this.

Findings

Of the nine included trials, only five reported adequately on placebo comparisons. No trials compared calcitonin with a standard analgesic.

Subcutaneous calcitonin

Four of four trials described benefit compared with placebo.

One trial of 172 patients who received salmon calcitonin within two weeks of fracture (50 IU daily for two to four weeks) showed greater pain relief with calcitonin.

One trial of 32 patients who received salmon calcitonin within two weeks of fracture (100 IU daily for four weeks) showed reduced pain and functional disability and decreased analgesic consumption after 14 days of treatment (70% versus 49% reduction in pain). It is unclear whether this benefit persisted for the remainder of the four week intervention.

One trial of 56 hospitalised patients who received salmon calcitonin within three days of fracture (100 IU daily for 14 days) showed reduced pain, decreased analgesic consumption from second day of treatment, and increased rate of mobilisation.

One trial of 60 patients who received synthetic human calcitonin within one year of fracture (either 0.25 mg or 0.125 mg three times weekly for one month) showed a dose-dependent reduction in pain by one month, but this was less clear for the remainder of the four month study. The reduction was significant.

Nasal

One small trial of 18 patients who received salmon calcitonin within one week of fracture (200 IU daily for two weeks) showed improvement in pain and decreased analgesic consumption.

Subcutaneous versus nasal calcitonin

One trial of 204 patients who received salmon calcitonin within two weeks of fracture compared subcutaneous calcitonin (50 IU daily) with intranasal calcitonin (200 IU daily) for one month. Pain relief, global assessment and adverse effects were similar for both groups.

Adverse effects

Reviewers report on findings from two subcutaneous trials. In 56 patients, treatment was well tolerated in 54% of patients, anorexia and flushing were experienced by 25% of patients, and nausea and vomiting by 21%. Placebo comparison not given. In 60 patients most common side effects were nausea, shivering, flushing and warmness (80% of high dose group and 35% of low dose group, placebo not given).

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