Late complications of SLE

A. Bhatia and R. W. Keen

Metabolic Unit, Royal National Orthopaedic Hospital Stanmore, Brockley Hill, Stanmore, Middlesex HA7 4LP, UK

SIR, We read with great interest the excellent review by Gordon regarding the late complications of SLE. She highlights that patients with SLE have an increased risk of osteoporosis and fracture. This appears to be due to both disease-related effects and to drug side-effects, particularly those of corticosteroids. When discussing drug treatment for osteoporosis she stated that the intranasal preparation of calcitonin may be harder to obtain than the subcutaneous preparation. We would like to provide some additional information on calcitonin in the management of patients with osteoporosis.

The history of calcitonin began in the early 1960s and is extensively reviewed in an article published by Colman et al. [1]. Reports of calcitonin's bone-sparing effect were reported in the early 1970s. Following the submission of data to the US Food and Drug Administration's (FDA) Division of Metabolic and Endocrine Drug Products, daily subcutaneous calcitonin injections for the treatment of postmenopausal osteoporosis were licensed in 1984 [1]. In 1994 the FDA approved the use of 200 IU daily of Miacalcin® (calcitonin-salmon) nasal spray for the treatment of postmenopausal osteoporosis in women who were more than 5 yr postmenopausal.

The Prevent Recurrence of Osteoporosis Fractures (PROOF) Study [2] demonstrated a statistically significant 33% decrease in the risk of developing vertebral fractures in patients with established osteoporosis treated with 200 IU daily of Miacalcic relative to treatment with vitamin D and calcium alone (placebo). The study also showed that, in patients who had one to five prevalent vertebral fractures, the risk of developing new vertebral fractures was statistically significantly reduced by 36% compared with vitamin D and calcium alone (the incidence of new fractures was 30% in the placebo group compared with 19% in the Miacalcic group). Although there has been some criticism regarding this study [3], intranasal Miacalcin® (salmon calcitonin) was licensed for use in established postmenopausal osteoporosis in the UK in October 2001 and is now readily available.

Both subcutaneous and intranasal preparations of calcitonin have also been used off-label to manage pain associated with acute osteoporotic vertebral fractures. Evidence from several randomized, placebo-controlled studies demonstrates that both preparations have a rapid onset and a strong analgesic effect on patients with acute vertebral fractures [4].

The ease of use of intranasal calcitonin together with a favourable side-effect profile may make it a popular choice of medication for postmenopausal osteoporosis and in those with acute vertebral fractures. In addition, the cost of 1 month's treatment with Miacalcin (200 IU daily) is £41.98 compared with a range of £106.80–256.50 (dependent on source) for 1 month of subcutaneous (100 IU daily) calcitonin.

Intranasal calcitonin is therefore another treatment option in patients with lupus who may already be overwhelmed by the number of oral medications they take daily or who are intolerant of oral medication for their osteoporosis.

Conflict of interest

The authors have declared no conflicts of interest.

Notes

Correspondence to: A. Bhatia. E-mail: ajay.bhatia{at}lineone.net Back

References

  1. Colman E, Hedin R, Swann J et al. A brief history of calcitonin. Lancet 2002;359:885–6.[CrossRef][ISI][Medline]
  2. Chesnut CH, Silverman S, Andriano K et al. A randomised trial of nasal spray salmon calcitonin in postmenopausal women with established osteoporosis: the Prevent Recurrence Of Osteoporotic Fractures study. Am J Med 2000;109:267–76.[CrossRef][ISI][Medline]
  3. Cummings SR, Chapurlat RD. What PROOF proves about calcitonin and clinical trials. Am J Med 2000;109:330–1.[CrossRef][ISI][Medline]
  4. Maksymowych WP. Managing acute osteoporotic fractures with calcitonin. Can Family Physician 1999;44:2160–6.[ISI]
Accepted 6 December 2002