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.
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.
Of the nine included trials, only five reported adequately on
placebo comparisons. No trials compared calcitonin with a standard analgesic.
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.
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.
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).
- Identifier CP104-5997: Mar-2000