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I would like the opportunity to correct, or possibly update, a number of the facts concerning calcitonin contained in Dr Patel’s comprehensive review article on drug treatments for osteoporosis.1
He states that nasal preparations of calcitonin are licensed for use in osteoporosis in ‘some European countries and Japan’, whereas in fact the nasal spray formulation of salmon calcitonin developed at Sandoz (now Novartis) is currently approved in more than 70 countries worldwide, including the USA and almost all the countries of Europe. Japan, on the other hand, has not yet granted marketing approval!
Regarding his claim that calcitonin has ‘significant’ side effects and is unlikely to gain widespread acceptance in osteoporosis, the evidence accumulated as a result of this extensive use does not bear this out. Neither the incidence nor the severity of side effects reported with the nasal spray can be described as significant, while in our experience its acceptance has been excellent –by both patients and physicians.
On the issue of cost, while I agree that calcitonin is much more expensive than standard analgesics, these are not without their disadvantages in terms of side effects, habituation potential, and tachyphylaxis. Where pain is associated with bone disease, salmon calcitonin has certainly proved extremely beneficial, and pain relief in patients with established osteoporosis is an important secondary indication for the preparation of the hormone.
It is perhaps also fair to add that, purely as a treatment for osteoporosis, calcitonin is hardly more expensive than alendronate, at least in the USA.
I thank Dr Azria for pointing out that nasal calcitonin is not licensed in Japan. In addition he is probably correct in stating that nasal calcitonin has few side effects and is acceptable, although this probably reflects lower bioavailability and potentially limited efficacy. As I indicated, there do not seem to be any long term side effects from calcitonin and this is in its favour. Certainly there will be a number of patients who may be intolerant to other compounds and for whom calcitonin, if available, should be considered.
With respect to pain relief, it makes common sense to use simple analgesics, such asparacetamol or paracetamol/codeine mixtures in the first instance, before consideration of salmon calcitonin. This, in my opinion would be good medical practice, particularly because salmon calcitonin would have to be given by a parenteral route. On the issue of cost, physicians will have to judge the suitability of drugs for osteoporosis depending on their interpretation of efficacy and local price for the individual compounds.
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