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Acute Pain | Chronic Pain | General

Managing acute osteoporotic vertebral fractures with calcitonin

Clinical bottom line:

There is evidence that calcitonin reduces pain from osteoporotic vertebral fractures, reduces consumption of analgesics, and improves disability, at the cost of some minor adverse effects. The review is unhelpful in describing the magnitude and significance of the effects.


For women, the lifetime risk of vertebral fracture is about 30%. It is a common management problem in primary care, and pain can last for many months and lead to disability and immobility.

Systematic review

WP Maksmowych. Managing acute osteoporotic vertebral fractures with calcitionin. Can Fam Physician 1998 44: 2160-2166.

Date review completed: 1997

Number of trials included: 9

Number of patients: 728

Control group: placebo

Main outcomes: Pain, usually as a VAS score, plus analgesic consumption and adverse effects.

Inclusion criteria were randomised, double blind, placebo controlled trials of the use of calcitonin as an analgesic for patients with acute vertebral fractures associated with osteoporosis.

Findings

This review, though systematic, did not give details of the results of the studies or attempt any meta-analysis or the results. Descriptions of the main results are given. Treatment was predominantly subcutaneous or intranasal salmon calcitonin at 50 to 200 IU per day, for 2-4 weeks, and usually within 1-2 weeks of fracture. Eight were placebo controlled and one compared intranasal and subcutaneous calcitonin. Outcomes were pain relief, analgesic consumption and, occasionally, measures of disability.

All eight placebo controlled studies showed benefit in terms of pain and/or analgesic consumption from baseline by one to four weeks. The extent of the pain reduction is not stated, and comparisons with placebo are not given in any way that makes a reader comfortable that the benefits are superior to measures with placebo. Information in the text indicates that benefits in pain reduction are better with calcitonin than with placebo. Where reported, mobility and functional disability also seemed to be improved. Adverse effects included nausea, local injection reactions and flushing, which tended to be minor rather than serious.

Comment

In many ways this is an unsatisfactory review. It will have identified relevant studies, but has not described them in ways that are immediately useful to prescribers or policy makers. A more thorough review is needed addressing the magnitude of benefits, the difference between calcitonin and placebo, and to adequately characterise the frequency of adverse effects.