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Forteo is more expensive than any of the anti-resorptive therapies. But based on your individual case, you may benefit more from Forteo. If you and your clinician decide that you need to take it, be sure to check with your insurance carrier. The manufacturers of Forteo have a customer service center, and they may be able to assist you in getting the medication covered. Without insurance, Forteo can cost about $650 per month.

A clinical trial has just recently begun to evaluate Forteo as an effective treatment option in women who have used either Fosamax or Actonel without success. In a study of women who had taken either Fosamax or Evista for almost three years, the women who had been on Evista and switched to Forteo built more bone mineral density, and more quickly, than the women who were switched from Fosamax to Forteo. Table 13 contains further information about Forteo.

63. I have a very small fracture in one of the bones in my back. I've been prescribedMiacalcin® (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 non-thyroid 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 SERMs), 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 14.

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.

Trade Name (Generic Name) [Manufacturer]

How Supplied Clinical Uses Contraindications

Miacalcin NS

  • calcitonin-salmon)
  • Novartis]

Nasal spray

3.7 milliliter/bottle; each dose contains about 200 IU of calcitonin Fortical

(calcitonin-salmon) [Unigene]

3.7 millilter/bottle; each dose contains about 200 IU of calcitonin

Postmenopausal women who have osteoporosis (in postmenopause >5 years)

Postmenopausal women who have a vertebral (spinal) fracture

Allergy to calcitonin-salmon

Most Common

Side Effects and Special Adverse Reactions Considerations

Interferes with osteoclasts to reduce bone breakdown

Increases BMD in lumbar vertebrae, but not as much as other prescription options for treatment of bone loss

Give one spray in one nostril every day; alternate the nostrils

Probably provides pain relief in women with vertebral (spinal) fractures; may be more helpful in this regard if given at bedtime

Use with caution in women with poor kidney function or pernicious (Vitamin B12) anemia Calcitonin sometimes given as injection for Paget's disease of bone

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