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332 Osteoporotic vertebral compression fracture
some arenas (see the chapter on cancer and tumor pain, p. 151), but there is
promise for its use in OVCF. Trials indicate that calcitonin is associated with
better pain relief and earlier mobilization than achieved with acetaminophen
monotherapy or placebo. 6–8
The exact mechanism of calcitonin’s analgesia provision is not known, but
effects can be expected as early as 48h after institution of therapy. 2,7–9 Metaanalysis
of five RCTs evaluating calcitonin versus placebo for acute OVCF
concluded that the drug significantly reduces pain, with an effect consistently
identified within seven days of treatment. 2 The reduction in pain score over
that associated with placebo is both long-lasting – persisting through four
weeks of follow-up – and substantial (over 3 units on a 10-point pain scale). 2
Calcitonin’s pain-relieving effects extend to reduction of discomfort associated
with sitting, standing, and walking. 2
Meta-analysis finds a potential trend toward faster pain relief with IM
calcitonin, although there are too few studies for definitive conclusions. 2
Evidence shows equivalence between IN and SC routes for calcitonin, and
data also demonstrate significant pain reductions with the PR formulation. 5,9
Therefore, there is little evidence base to recommend one administration
route over another.
Where specified, the majority of the studies use salmon calcitonin. There
are no studies comparing the effectiveness of salmon-derived versus synthetic
forms of the hormone. If patients are not allergic to fish products, the
salmon-derived formulation seems a reasonable choice.
There are no studies that specifically address the utility of calcitonin in the
ED. There is also an absence of data addressing use of calcitonin for nonosteoporotic
compression fractures. In our judgment, it is reasonable to
extrapolate non-ED evidence of calcitonin’s pain relief efficacy to the acute
care setting for OVCF. We are less convinced about the appropriateness of
extrapolating evidence of calcitonin’s efficacy in osteoporotic fracture pain to
compression fractures not related to osteoporosis.
Like calcitonin,thebisphosphonates have been studied for bony tumor and
cancer-related pain (see the chapter on cancer and tumor pain, p. 151). There
is less evidence addressing their use for OVCF. One placebo-controlled OVCF
trial found pamidronate improved pain. 10 Another study found similar pain