I have a very small fracture in one of the bones in my back. I've been prescribed Miacalcin® (calcitonin) in a nasal spray. What is Miacalcin? Can a nasal spray be effective for treating a bone fracture? Is Fortical® (calcitonin) nasal spray the same as Miacalcin?

Calcitonin is a hormone secreted by the nonthyroid cells in the thyroid gland that plays an important role in maintaining bone strength and regulating blood levels of calcium. Manufactured calcitonin is sold under the trade names of Miacalcin and Fortical. Miacalcin Nasal Spray and Fortical (calcitonin-salmon) are manufactured forms of calcitonin with action essentially identical to those made in the body but with greater potency and longer duration. They have the same amino acids as the calcitonin found in salmon, which is why they're often designated as calcitonin-salmon. Calcitonin is one of the earliest discovered treatments for osteoporosis. Formerly given as a subcutaneous injection, Miacalcin NS is now taken as a once-a-day nasal spray. Fortical is also a once-a-day nasal spray, but has never been available as a subcutaneous injection. Calcitonin decreases osteoclasts to prevent further bone breakdown.

Miacalcin NS and Fortical are indicated in the treatment of low bone mass in women who have been in postmenopause for at least 5 years or for whom estrogen is not an option. The PROOF (Prevent Recurrence of Osteoporotic Fractures) Trial showed that 200 IU per day of Miacalcin reduced spinal fractures by 33%; however, 5 years of treatment with Miacalcin did not reduce overall fracture rates. Surprisingly, even women who took 400 IU of Miacalcin did not have reduced fracture risk, but because many women did not complete the study, the results may have been distorted. According to Miacalcin's prescribing information, it does not increase BMD in other bones besides the spine. Studies evaluating Fortical similarly demonstrated increases in bone density at the spine.

Calcitonin has been used successfully for pain relief in women who have had spinal fractures, although it is not FDA-approved as an analgesic. While few studies have evaluated pain relief with calcitonin, many personal reports of pain relief support this use. It is often taken at bedtime because calcitonin nasal spray gets into your system rapidly and reaches peak blood levels in 30 minutes. When taken as a nasal spray, it is used as one spray in one nostril every day, alternating nostrils daily. The nasal spray is dispensed from a pump and bottle. The pump must be primed before using for the first time, but it should not be primed before each dose. Unopened bottles should be stored in a refrigerator but not frozen. Before the first dose of the 30-dose container is used, the contents should reach room temperature, and the remaining amount should then be stored at room temperature.

So, although Miacalcin and Fortical (calcitonin) can be prescribed for postmenopausal osteoporosis, they are rarely the first choice for osteoporosis-related fractures. Instead, calcitonin is usually used in combination with other therapies (such as estrogen or estrogen agonists/ antagonists), and most often following a vertebral fracture for its pain-relieving effects. Like all prescription therapies for osteoporosis prevention and treatment, calcitonin nasal spray should be taken with calcium and adequate vitamin D. Consideration for medication cost must also be weighed, as long-term therapy with Miacalcin NS can cost thousands of dollars per year. See a summary of Miacalcin NS's and Fortical's indications, side effects, and special considerations in Table 15.

Penny's comment:

When you stop to think about it, cleaning up after dinner is not usually a difficult task. But as I leaned into the refrigerator, I felt the pain in my back. I couldn't breathe or scream. Bent over and twisted sideways, I finally made it to my bed. By then I could scream for the heating pad and two Aleve tablets.

The next morning, I was off to see my orthopedic doctor (every person over 65 should have one), who told me that

Table 15 Miacalcin Nasal Spray and Fortical (calcitonin-salmon)

Miacalcin Nasal Spray and Fortical (calcitonin-salmon)

I had a compression fracture of the thoracic vertebra #5. Getting on and lying on the x-ray table was excruciating.

I was fitted for a brace, made in two sections of stainless steel, one just above the groin area, and the upper steel brace just hitting the top of the breast bone, all connected with a plastic 6-inch-wide belt, suspended between the two steel braces and intended to torture me by keeping my back straight. I looked in the mirror. I bulged in all the wrong places. I looked like an ink blot test waiting to be analyzed— bumps and ridges never before a part of my torso.

I had to wear the brace during the day for about 6 weeks. My doctor prescribed Miacalcin nasal spray and some pain medication. Although I later learned that this fracture indicated that I have osteoporosis, I wasn't told that at the time. Now I need to be more aware of what I can and cannot do. I need to learn to bend at the knees, keeping my back straight—no more bending over to put stuff in the refrigerator or the oven! Although I was told that only the first vertebra fracture causes pain, I have since heard that is not true. I just can't believe that a fracture in my spine wouldn't hurt every time it happens!

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