Calcitonin is an effective nonnarcotic medication for osteoporotic compression fracture pain
Osteoporotic vertebral compression fractures can hurt—a lot—in a population of patients that does not easily tolerate the usual cocktails of narcotics and nonsteroidal anti-inflammatory medications. Yet, orthopaedic surgeons have largely ignored an effective agent that has been specifically shown to decrease spine–fracture-related pain.

As the Impactful Statement from the AAOS Treatment of Symptomatic Osteoporotic Spinal Compression Fractures Clinical Practice Guideline (CPG) reads: "Using calcitonin for 4 weeks helps manage pain associated with an acute osteoporotic spinal compression fracture."

Admittedly, calcitonin is not the first medication that comes to mind when considering an analgesic. More likely, it is recalled as one of the agents that can decrease blood levels of calcium. Yet, possibly related to its inhibition of osteoclasts, calcitonin has been shown to reduce pain from compression fractures in several high quality clinical trials, as identified from the systematic literature review of the AAOS CPG.

Of note, calcitonin can be administered several ways. Intranasal calcitonin was better than placebo in one randomized controlled trial involving 100 patients; calcitonin suppositories were similarly effective in another randomized trial involving 36 patients. Importantly, the medication was administered within 5 days of the fracture event and reduced pain for up to 4 weeks. Lower quality studies suggest a possible benefit over longer periods (3 months to 12 months) following fracture.

Considering these data, the question remains: How many of us are prescribing or recommending calcitonin to affected patients?

Scope of the problem
Osteoporosis affects about 10 million individuals in the United States. It is characterized by a critical decrease in bone mineral density, defined by the World Health Organization as less than 2.5 standard deviations below that of normal peak bone mass in a healthy adult. About 25 percent of postmenopausal women will sustain a vertebral compression fracture, with an overall incidence that is higher than fragility fractures of the hip and wrist. With our aging society, the already high cost associated with managing these fractures will assuredly rise in the future.

Using calcitonin for osteoporotic vertebral fracture pain isn't the only treatment for osteoporosis that is ignored by orthopaedic surgeons. Failure to initiate pharmacologic treatment of osteoporosis, either before or after a fracture event, has long been an area of concern in the orthopaedic literature. Hip and wrist fractures encountered by orthopaedic surgeons have been recognized as "missed opportunities" to initiate anti-osteoporotic medications, which have been clearly demonstrated in a multitude of studies to decrease subsequent fracture risk. Unfortunately, vertebral compression fractures are often a sentinel sign of osteoporosis, with treatment focused on the fracture itself and not the underlying metabolic disorder.

These injuries should get our attention. Osteoporotic compression fractures can forecast an even higher mortality risk than geriatric hip fractures. But because they are less clinically obvious, they often go undiagnosed. Notwithstanding their effects on spinal alignment, the primary complaint and driver of disability from compression fractures is pain. Thus, pain is the primary driver of treatment—even invasive treatments such as vertebroplasty and kyphoplasty.

Typical nonsurgical options to treat pain from osteoporotic compression fractures include analgesics, bracing, and physical rehabilitation. Bed rest should be avoided because it can potentiate further bone mineral density loss as well as other complications such as decubitus ulcers, thromboembolic disease, pneumonia, and urinary tract infections.

Minimally invasive surgical treatments, such as percutaneous cement augmentation, were once touted as revolutionary advances to address fracture-related pain. However, high-quality blinded, randomized controlled trials have called the efficacy of these treatments into question, as reflected in the tempered recommendations in the AAOS CPG. Open surgery is rarely performed, and is reserved to treat those with neurological deficits associated with canal compromise caused by a fracture.

The silver lining of vertebral compression fractures is that in most patients (about two-thirds), fracture pain resolves within a few weeks. During these weeks, however, pain can be considerable and its management difficult. Half-lives of narcotics are extended in the elderly, which can predispose them to delirium and other unwanted systemic effects. Any effective alternative would be highly welcome.

Why not try it?
Calcitonin appears to be a relatively safe medication; mild dizziness is the most commonly reported side effect. Other possible side effects include itchiness, nausea, vomiting, eye pain, foot swelling, and increased nocturnal urination.

In short, think about calcitonin for your next patient with an acutely symptomatic osteoporotic vertebral compression fracture. Whether it's you, a hospitalist, or the patient's primary care doctor writing the prescription, you may find it makes a world of difference for your patient's pain management.

Christopher M. Bono, MD, is an adult spine surgeon at Brigham and Women's Hospital. an associate professor of orthopaedic surgery at Harvard Medical School in Boston, and a member of the AAOS Committee on Evidence-Based Quality and Value