salmon

Action

Directly affects bone, kidney, and GI tract. Decreases osteoclastic osteolysis in bone; also reduces mineral release and collagen breakdown in bone and promotes renal excretion of calcium. In pain relief, acts through prostaglandin inhibition, pain threshold modification, or beta-endorphin stimulation.

Availability

Injection: 0.5 mg/ml (human), 1 mg/ml (human), 200 international units/ml in 2-ml vials (salmon)

Nasal spray (salmon): 200 international units/actuation, metered nasal spray in 3.7 ml-bottle

Indications and dosages

➣ Postmenopausal osteoporosis

Adults: Calcitonin (salmon)-100 international units/day I.M. or subcutaneously, or 200 international units/day intranasally with concurrent supplemental calcium and vitamin D

➣ Paget's disease of bone (osteitis deformans)

Adults: Calcitonin (salmon)-Initially, 100 international units/day I.M. or subcutaneously; after titration, maintenance dosage is 50 to 100 international units daily or every other day (three times weekly). Calcitonin (human)-0.5 mg I.M. or subcutaneously daily, reduced to 0.25 mg daily.

➣ Hypercalcemia

Adults: Calcitonin (salmon)-4 international units/kg I.M. or subcutaneously q 12 hours; after 1 or 2 days, may increase to 8 international units/kg q 12 hours; after 2 more days, may increase further, if needed, to 8 international units q 6 hours.

Contraindications

• Hypersensitivity to drug or salmon

• Pregnancy or breastfeeding

Precautions

Use cautiously in:

• renal insufficiency, pernicious anemia

• children.

Administration

☞ Before salmon calcitonin therapy begins, perform skin test, if prescribed. Don't give drug if patient has positive reaction. Have epinephrine available.

• Bring nasal spray to room temperature before using.

• Give intranasal dose as one spray in one nostril daily; alternate nostrils every day.

• To minimize adverse effects, give at bedtime.

• Rotate injection sites to decrease inflammatory reactions.

Adverse reactions

CNS: headache, weakness, dizziness, paresthesia

CV: chest pain

EENT: epistaxis, nasal irritation, rhinitis

GI: nausea, vomiting, diarrhea, epigastric pain or discomfort

GU: urinary frequency

Musculoskeletal: arthralgia, back pain

Respiratory: dyspnea

Skin: rash

Other: altered taste, allergic reactions including facial flushing, swelling, and anaphylaxis

Interactions

Drug-drug. Previous use of bisphosphonates (alendronate, etidronate, pamidronate, risedronate): decreased response to calcitonin

Patient monitoring

• Monitor for adverse reactions during first few days of therapy.

• Assess alkaline phosphatase level and 24-hour urinary excretion of hydroxyproline.

• Check urine for casts.

• Monitor serum electrolyte and calcium levels.

Patient teaching

• Instruct patient to take drug before bedtime to lessen GI upset. Tell him to call prescriber if he can't maintain his usual diet because of GI upset.

• Inform patient using nasal spray that runny nose, sneezing, and nasal irritation may occur during first several days as he adjusts to spray.

• Instruct patient to bring nasal spray to room temperature before using.

• Advise patient to blow nose before using spray, to take intranasal dose as one spray in one nostril daily, and to alternate nostrils with each dose.

• Tell patient to discard unrefrigerated bottles of calcitonin (salmon) nasal spray after 30 days.

• Encourage patient to consume a diet rich in calcium and vitamin D.

• As appropriate, review all other significant adverse reactions and interactions, especially those related to the drugs mentioned above.