Calcitonin (salmon)

FDA label

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Titration Hypercalcemia only: wait 1–2 days at 4 IU/kg q12h before the first increase, then 2 more days before the second increase.

Renal Undefined

Hepatic Undefined

Instructions

• SC or IM injection; if the volume exceeds 2 mL, use IM and distribute the total dose across multiple injection sites.
• Inspect visually — solution must be clear and colorless; do not administer if discolored, particulate, or the vial is damaged.
• Instruct patients on sterile injection technique and proper needle disposal.
• Correct hypocalcemia and treat other mineral-metabolism disorders (e.g. vitamin D deficiency) BEFORE initiating.
• Postmenopausal osteoporosis: give with at least 1000 mg elemental calcium and at least 400 IU vitamin D daily; ensure adequate calcium and vitamin D intake in Paget's disease as well.
• Consider skin testing with a dilute sterile solution before treatment in patients with suspected calcitonin-salmon hypersensitivity.

Cautions

• Serious hypersensitivity including bronchospasm, tongue/throat swelling, anaphylactic shock and fatal anaphylaxis — have medical support and monitoring available; consider pre-treatment skin testing in suspected hypersensitivity.
• Hypocalcemia with tetany (muscle cramps, twitching) and seizures — correct before starting; have parenteral calcium available for the first several doses in at-risk patients and monitor serum calcium.
• Malignancy: meta-analysis of 21 trials showed higher overall malignancy incidence (4.1% vs 2.9% placebo); an increased risk with parenteral long-term use cannot be excluded — weigh benefit against risk.
• Circulating anti-calcitonin antibodies may develop (about half of Paget's patients studied at 2–18 months) and can cause loss of response.
• Urine sediment abnormalities (coarse granular casts, renal tubular epithelial casts) reported — consider periodic urine sediment examination.

Adverse reactions

• Nausea ± vomiting ~10% — worst at initiation, tends to decrease with continued use.
• Injection-site inflammatory reactions ~10%.
• Flushing of face or hands 2–5%; skin rash, pruritus of the ear lobes.
• Nocturia, feverish sensation, eye pain, poor appetite, abdominal pain, pedal edema, salty taste.
• Postmarketing: urticaria, hypocalcemic tetany/seizures, influenza-like symptoms, fatigue, edema, arthralgia, musculoskeletal pain, hypertension, diarrhea, polyuria, dizziness, headache, paresthesia, tremor, visual disturbance.

Pregnancy No human studies; in rabbits, SC dosing at 4–18× the recommended human parenteral dose decreased fetal birth weight (no adverse effect in rats at 9× by BSA).

Lactation No information on presence in human milk or effects on the breastfed child; calcitonin inhibits lactation in rats — weigh benefits of breastfeeding against maternal need.