Calcitonin (Miacalcic) for Hypercalcemia and Paget's disease

Calcitonin inhibits bone resorption by inhibiting the activity of the parathyroid hormone. It is used to treat the following conditions:

  • for the treatment of hypercalcemia, particularly in situations of urgency where a quick drop in serum calcium is needed.

  • for the treatment of individuals with symptomatic Paget disease of the bone (osteitis deformans) who are resistant to or intolerant of alternate treatments.

  • for the treatment of osteoporotic postmenopausal women. Although it is not a favored long-term medication, it may be useful in treating acute spinal fracture patients' pain.

Calcitonin Dose in Adults

Note: When used to treat Paget's disease, calcium, and vitamin D supplementation should be added to the treatment regimen.

Use in the treatment of symptomatic Paget disease:

  • 100 units daily as an intramuscular or a Subcutaneous injection:
  • A lower maintenance dose of 50 units thrice weekly may be sufficient.

Use in the treatment of Hypercalcemia:

  • 2 times daily intramuscular or subcutaneous injections of 4 units/kg.

  • In patients who do not respond adequately after 24 to 48 hours, the dosage may be raised to 8 units/kg twice a day.

  • If necessary, the dosage can be raised to 8 units/kg administered four times each day.

Use in the treatment of Postmenopausal osteoporosis:

  • 100 units daily as an intramuscular or subcutaneous injection.
  • 200 units that are equivalent to 1 spray intranasal in one nostril once a day
    • It is not a preferred treatment for osteoporosis.
    • Short-term treatment may provide an analgesic effect, especially in patients with acute vertebral fractures.

Calcitonin Dose in Children

Use in the treatment of Osteogenesis imperfecta:

  • Infants older than 6 months, Children, and Adolescents:
    • 2 units per kg per dose intramuscular or subcutaneous three times per week.

Pregnancy Risk Factor C

  • Although data are limited regarding its use during pregnancy, it does not cross the placental boundary.

Calcitonin use during breastfeeding:

  • Lactating mothers should use it with caution. It is important to weigh the benefits and risks for the mother as well as the potential dangers for the child from calcitonin.
  • Breast milk is usually enriched with endogenous calcium for lactating mothers.

Calcitonin Dose in Renal Disease:

The manufacturer has not recommended any adjustment in the dose in patients with renal disease.

Calcitonin Dose in Liver Disease:

The manufacturer has not recommended any adjustment in the dose in patients with liver disease.

Common Side Effects Of Calcitonin Include:

  • Respiratory:
    • Rhinitis

Less Common Side Effects Of Calcitonin Include:

  • Cardiovascular:
    • Flushing
  • Dermatologic:
    • Erythematous rash
  • Central nervous system:
    • Depression
    • Dizziness
    • Paresthesia
  • Gastrointestinal:
    • Nausea
  • Infection:
    • Infection
  • Hematologic & oncologic:
    • Malignant neoplasm
    • Lymphadenopathy
  • Local:
    • Injection site reaction
  • Ophthalmic:
    • Abnormal lacrimation
    • Conjunctivitis
  • Neuromuscular & skeletal:
    • Back pain
    • Myalgia
    • Osteoarthritis
  • Respiratory:
    • Upper respiratory tract infection
    • Bronchospasm
    • Flu-like symptoms
    • Sinusitis

Contraindications to Calcitonin include:

  • Allergy reactions to calcitonin salmon and any component of this formulation

Warnings and Precautions

  • Hypersensitivity reactions
    • Products derived from salmon:
      • Before initiating calcitonin treatment, patients should be tested for allergic reactions.
      • Medications like epinephrine should be available if severe hypersensitivity reactions occur.
      • Anaphylactic shock, anaphylaxis, and swelling of the throat or tongue may all be possible.
  • Hypocalcemia:
    • It is used primarily to treat hypercalcemia. Hypocalcemia may manifest as seizure or tetany.
    • Calcium and vitamin D supplementation are recommended when treating osteoporosis or Paget's disease.
    • During therapy, it is important to monitor vitamin D and calcium levels.
  • Malignancy
    • Studies have shown that chronic use of calcium has been linked to malignancies. It is important to screen patients regularly, especially for new symptoms.
  • Osteoporosis
    • It's possible that patients with early postmenopausal bone loss won't be able to gain from this.
    • There is no evidence that calcitonin helps lessen fractures.
    • The mineral density of the spine does not increase when calcitonin is present.
    • It should only be used by postmenopausal females to treat osteoporosis. Alternative treatments might not be wise.
    • For individuals with severe spinal injuries, it may offer momentary pain relief.
  • Nasal spray:
    • Nasal sprays can cause changes in the mucosa, resulting in rhinitis or epistaxis.
    • An examination of the nose should include the examinations of the turbinates and mucosa.
    • If the patient has deep ulcerations of more than 1.5mm or ulcers that penetrate the mucosa, it is best to stop treatment.

Calcitonin: Drug Interaction

Note: Drug Interaction Categories:

  • Risk Factor C: Monitor When Using Combination
  • Risk Factor D: Consider Treatment Modification
  • Risk Factor X: Avoid Concomitant Use

Risk Factor C (Monitor therapy).

Lithium Calcitonin could lower the serum level of Lithium.
Zoledronic Acid Calcitonin could increase the hypocalcemic effects of Zoledronic acid.

Risk Factor D (Consider therapy modifications)

Sincalide Sincalide may be less effective if drugs that affect gallbladder function are taken. Management: Before Sincalide is used to stimulate the gallbladder, discontinue any drugs that affect gallbladder motility.

Monitor the following parameters:

  • Osteoporosis:
    • Monitor bone mineral density (BMD) every 1 - 2 years after initiating therapy and every 1 - 2 years or less frequently if stable thereafter
    • Measure height and weight annually
    • Assess chronic back pain
    • Serum calcium and Vitamin D levels
  • Paget disease:
    • Alkaline phosphatase
    • Pain
    • Serum Calcium
    • Vitamin D levels
  • Nasal formulation:
    • Visualize the nasal mucosa, turbinate, septum, and blood vessels at baseline and in patients with nasal complaints.

How to administer Calcitonin?

  • It may be administered as an intramuscular or Subcutaneous injection. The intramuscular route is preferred if the volume is more than 2 mL.
  • The subcutaneous route is preferred for outpatient self-administration if the volume of injection is less than 2ml.

Calcitonin Nasal spray:

  • Allow the bottle to reach room temperature.
  • Prime the pump by releasing it until a full spray is produced.
  • Place the nozzle into the nostril with the head in an upright position.
  • Use in the alternate nostrils daily.
  • Discard after 30 doses.

Mechanism of action of Calcitonin:

  • Calcitonin counteracts the effects of the parathyroid hormone.
  • It inhibits osteoclastic bone loss and promotes the excretion of calcium phosphate, sodium magnesium, potassium, and potassium from kidneys through reducing reabsorption.
  • It increases the secretion of water and sodium in the jejunal glands. For the treatment of hypercalcemia, when administered intramuscularly or subcutaneously,

it has an onset of action of about 2 hours. Patients with Paget's disease may experience neurologic symptoms that last for months or even years. It has a duration of action of 6 - 8 hours following administration of multiple doses AbsorptionThe intranasal route is faster but less efficient than Intramuscular administration. It is metabolized it is found in the blood, kidneys, and peripheral tissues. It is bioavailable at 66% after intramuscular administration, and 71% following subcutaneous administration. It has a terminal half-lifeIt takes 58 minutes to administer intramuscular injections, 59 -64 minutes for subcutaneous injections, and 18 – 23 minutes after nasal administration. The time to reach plasma peak concentrations takes between 23 and 13 minutes to subcutaneously administer the medication, while it takes 10 to 13 minutes for nasal administration. It is excreted via urine as inactive metabolites

International Brands of Calcitonin:

  • Cadens
  • Calci-10
  • Calcinin
  • Calcitoran
  • Calco
  • Calco [salmon]
  • Calsonin
  • Calsynar
  • Calsynar [salmon]
  • Cibacalcin
  • Cibacalcine [human]
  • Citonina
  • Forcaltonin
  • Karil
  • Karil [salmon]
  • Miacalcic
  • Miacalcic [salmon]
  • Miakaltsyk
  • Mycalcin
  • Nozocalcin
  • Orthonase
  • Oseum
  • Osteocal
  • Salco
  • Salmocalcin
  • Salmocin
  • Tonocalcin
  • Ucecal [salmon]
  • Zycalcit

Calcitonin Brands in Pakistan:

Miacalcic Injection (100 IU/ampule) - Novartis Pharmaceuticals PVT LTD