Equivalence of Nasal Spray and Subcutaneous Formulations of Salmon Calcitonin

The aim of this study was to assess the efficacy and safety of nasal spray and subcutaneous formulations of salmon calcitonin. Two-hundred-four patients, 27 males and 177 females, aged 72 years on average, with a recent, painful, vertebral crush fracture were given either 50 IU/day of subcutaneous salmon calcitonin (SCSCT, 102 patients) or 200 IU/day of intranasal salmon calcitonin (INSCT, 102 patients) for 30 consecutive days, according to a double-blind, double-placebo design. The two-sided 95% confidence interval of the difference between the two formulations for the pain on D30 assessed by Huskisson's Visual Analogue Scale (VAS) [−5.3 mm, 7.9 mm] was included in the [−10 mm, 10 mm] reference interval. Equivalence of the two formulations, was demonstrated. At the end of the study, the 95% confidence intervals of VAS of both treatment groups were included in the [0 mm, 30 mm] interval, which is considered to be clinically pertinent. Relief was obtained in less than 10 days for more than 50% of patients. The urinary hydroxyproline/creatinine and calcium/creatinine ratios remained constant between D1 and D30 with both formulations. General safety was comparable between the two formulations. Local safety of INSCT was similar to that of its placebo. Received: 13 August 1996 / Accepted: 31 December 1996     

降钙素对雄性去势大鼠骨丢失的预防作用

雄激素减少是老年男性原发性骨质疏松症形成的重要原因之一。本研究以雄性大鼠去势造成骨质疏松症动物模型，观察雄激素对骨质丢失的影响，并观察降钙素对骨质疏松症的预防作用。结果显示雄性大鼠去势后骨量显著降低。骨钙素及２４小时尿羟脯氨酸显著升高，提示为高转化型骨质疏松症。形态计量学显示会势后大鼠骨量减少主要表现为小梁骨厚度的减少，小梁连续性尚可，尚未出现断裂及穿孔。降钙素可抑制骨吸收，增加骨量，改善骨结构的异常，可预防去势大鼠骨质的丢失。     

Suppression of Bone Resorption in Early Postmenopausal Women by Intranasal Salmon Calcitonin in Relation to Dosage and Basal Bone Turnover

In the present study, we assessed the ability of increasing doses of intranasal calcitonin to suppress urinary deoxypyridinoline cross-link (DPD), a specific biochemical marker of bone resorption, in early postmenopausal women. Subjects consisted of 30 healthy Thai women within 5 years of postmenopause, randomly assigned to 50, 100, or 200 IU of intranasal calcitonin 5 days/week for 3 months. Calcium supplementation by calcium carbonate capsules at 750 mg of elemental calcium per day was given to all subjects. Twenty four-hour urine for DPD and creatinine assays was collected at baseline, 1 month, and 3 months after treatment. All DPD values were corrected with urinary creatinine before analyses. Data were expressed as mean ± SEM. DPD decreased significantly 1 month after intranasal calcitonin treatment (P < 0.01). However, at 3 months, DPD increased when compared with the values at 1 month (P < 0.01), suggesting that there may be a reduction in the suppression of bone resorption after prolonged calcitonin therapy. Using a stepwise multiple regression model to address whether dosage and DPD at baseline influence the response to intranasal calcitonin, it was found that DPD suppression after intranasal calcitonin was not related to dosage but was strongly associated with baseline DPD (P < 0.0001). Suppression of bone resorption in early postmenopausal women by intranasal calcitonin is determined more by the state of bone turnover at baseline than the dosage of calcitonin. Received: 10 March 1997 / Accepted: 14 November 1997     

A Simulation Model at Trabecular Level to Predict Effects of Antiresorptive Treatment after Menopause

Antiresorptive drugs are widely used to prevent osteoporotic fractures in men and women. Large clinical trials have shown vertebral fracture risk reductions up to 50%, resulting from relatively small increases of 3–8% in bone mineral density (BMD). We developed a computer model that mimics bone turnover in human vertebral cancellous bone during menopause and antiresorptive treatment. This model links cell activity in trabeculae to changes in bone volume and mechanical properties. We asked whether treatment started shortly after menopause is better than treatment started late after menopause. In order to answer this question we used the model to simulate menopause and 5 years of anti-resorptive treatment with two different agents: one incorporated in the tissue, one not incorporated. We found that late treatment can result in almost the same bone mass as early treatment, but early treatment is much better in conserving the strength and stiffness of the cancellous bone. The effect of the incorporation of drugs in the tissue (giving the drugs a long half-life) was small. After discontinuation of treatment, bone was lost slower, but after 20 years the difference between the incorporated and the not incorporated drug in stiffness and bone volume was below 3%. This kind of simulation model may be used to preclinically test new pharmaceuticals and treatment protocols and to predict long-term effects of treatment before patient data become available.     

Effect of Salmon Calcitonin on Femoral Bone Quality in Adult Ovariectomized Ewes

The aim of this study was to evaluate the effect of intermittent calcitonin on femoral bone quality in adult ewes from the time of ovariectomy. Six months after the start of the experiment, bone density measurements and mechanical testing (torsion and resonant frequency analysis of the diaphysis and compression of an excised trabecular bone cylinder from the femoral neck) were performed in sham-control and ovariectomized (OVX) ewes treated with placebo or salmon calcitonin (50 or 100 units, 3 times/week). Crystallinity of bone was evaluated by measuring X-ray diffraction line broadening. After OVX, a nonsignificant bone loss was found at all measured sites in the femur (−3 to −9%) together with a decreased biomechanical competence in the trabecular bone (compressive strain −28%, P < 0.05). Treatment with salmon calcitonin, 50 or 100 IU subcutaneously three times a week from the time of ovariectomy, resulted in a significant dose-dependent preservation of bone strength in the trabecular bone of the femoral neck compared with OVX. No adverse effects of calcitonin were observed on bone crystal composition as assessed by diffractiometry. We conclude that in adult ewes intermittent calcitonin treatment from the time of OVX was associated with a significant preservation of cancellous bone strength and strain in trabecular bone of the femoral neck, without affecting crystalline properties of bone. Received: 20 October 1995 / Accepted: 19 February 1996     

Drug Delivery

The calculations necessary to allow infusion of a known drug dosage at micrograms per kilogram of body weight per minute are time-consuming and error prone. A simpler method entails multiplication of the patient's weight in kilograms by the factor 15. The resultant figure represents the number of milligrams of drug to be placed in 250 ml of infusate vehicle. The solution, which is delivered through a microdrip chamber (60 gtt per milliliter), will contain 1 μg per kilogram in each drop. One is thus permitted to define dosage by setting up the solution to have 1 gtt = 1 μg/kg.     

鲑鱼降钙素对人乳腺癌细胞生长作用的实验研究

目的：观察鲑鱼降钙素（sCT)在体外对人乳腺癌细胞生长的影响。方法：体外培养人乳遥癌细胞系MCF－7，细胞计数法观察sCT对细胞生长的影响，透射电镜和DNA电泳法观察凋亡，流式细胞仪检测细胞周期和凋亡率。结果：sCT实验组乳腺癌细胞的数量较对照组减少（P＜0．05），透射电镜观察到凋亡小体，DNA电泳出现梯状条带，细胞凋亡率由3．72％升高至23．37％，G2期细胞比例由0．88％升高至4．13％，结论：sCT体外能抑制人乳腺癌细胞生长，诱导乳腺癌细胞凋亡和调节细胞周期。     

The increase in spinal bone density that occurs in response to fluoride therapy for osteoporosis is not maintained after the therapy is discontinued

In 44 osteoporotic subjects who had been treated with fluoride for 37±16 months, the fluoride was discontinued because they had shown fluoride-dependent increases in trabecular spinal bone densities from low initial levels (below the fracture threshold) to values that were equivalent to normal peak bone densities in the spines of young adults. During the subsequent period, after discontinuation of the fluoride therapy (i.e. 19±9 months), spinal bone density decreased in 73% of the subjects (i.e. 32 of 44,p<0.03), at a rate that was comparable to the rate of the previous gain that had occurred during the treatment with fluoride (i.e. –3.23±2.39 mg/cm³ per month, compared with +3.91±1.96 mg/cm³ per month in this subgroup of patients,p<0.001). Although 9 of the 44 subjects showed continuing increases in spinal bone density after discontinuation of the fluoride therapy, spinal bone density decreased in the entire group of 44 at an average rate of –1.02±4.72 mg/cm³ per month (p<0.001, compared with the rate of the previous gain during the treatment with fluoride; i.e. +3.83±1.82 mg/cm³ per month). Surprisingly, our data showed that the rate of decrease in spinal bone density during the post-fluoride period was not affected by concurrent (undesigned) treatment with calcium, calcium plus estrogen, or calcium plus calcitriol. The cessation of fluoride therapy was also associated with a decrease in serum alkaline phosphatase activity (i.e. a decrease from the elevated levels that were observed during the period of fluoride therapy, back to the original, pre-treatment levels;p<0.001), and that the rate of spinal bone loss after cessation of fluoride could be correlated with the prior rate of increase in serum alkaline phosphatase activity that had occurred during the treatment with fluoride (n=44,r=0.312,p=0.039). Together, the observations from this retrospective analysis of data obtained from our clinical subjects suggest that fluoride-treated osteoporotic subjects who have exhibited increases in trabecular spinal bone density are at risk for bone loss after discontinuation of the fluoride therapy.     

Effects of Salmon Calcitonin on Synthesis and Mineralization of Collagen in Rats

The effects of salmon calcitonin (CT) on collagen metabolism and mineral deposition in fractures and intact femora, and on collagen metabolism in healing skin wounds and intact skin have been studied in young male rats. Serum calcium and serum phosphorus were reduced 3 h after the daily subcutaneous CT injection (3 MRC-U/kg body weight), whereas a rebound increase in the serum levels of both minerals was observed at 24 hours after the injection.

CT had an early transient inhibitory influence on the collagen synthesis, and this resulted in a reduced total content of collagen in bones and skin specimens from treated rats compared to controls. the concentration of collagen in bone and skin was, however, increased in treated animals compared to controls after prolonged CT administration.     

Bone and primary hyperparathyroidism

Primary hyperparathyroidism (PHPT) is a disease caused by excessive and inappropriate secretion of parathyroid hormone resulting in hypercalcemia. It is usually diagnosed incidentally in case of hypercalcemia, osteoporosis or, more rarely, renal involvement such as lithiasis. The clinical presentation reflects hypercalcemia and involves several organs, mainly the cardiovascular system, bone, and kidneys. However, most patients with PHPT are asymptomatic. The diagnosis is biological, obvious when serum calcium and parathyroid hormone levels are high, but difficult when one of these two values is normal. The diagnosis of normocalcemic PHPT is possible only after ruling out all causes of secondary hyperparathyroidism. Parathyroid imaging does not contribute to the positive diagnosis but guides surgery and rules out an associated thyroid abnormality. Parathyroid surgery is the gold standard treatment. Parathyroid surgery is indicated in the presence or risk of complications, and it is the only treatment that prevents fractures. Pharmaceutical treatments have only limited effects on complications and are limited to cases where surgery is contraindicated. After parathyroid surgery, the use of bisphosphonates must be avoided as they seem to interfere with the parathyroidectomy's fracture-preventing effects. In the absence of surgical indication, medical monitoring of patients includes assessment of laboratory values, bone density, and renal function.     

Effects of Intranasal Salmon Calcitonin in Juvenile Idiopathic Arthritis: An Observational Study

The aim of this study was to follow the changes in bone mineral density (BMD) and biochemical markers of bone turnover in 10 children (7.5-17.5 years of age) with severe juvenile idiopathic arthritis (JIA), during a 3-year therapy with salmon calcitonin (100 IU/day 2 months on and 2 off for a year and 200 IU/day for 2 years) and calcium (500 mg/day). All patients were functional classes III and IV and were measured at yearly intervals with a dual photon absorptiometer at the lumbar spine. The changes observed were 7.2-9.5% per year for BMD and 2.0-6.0% for volumetric bone mineral density (BMDvol). The bone resorption markers showed significant decreases after a year's treatment (Pyr/Cr from 175+/-15 to 108+/-15 nm/mm, P < 0.001, Pyr-D/Cr from 24.3+/-3.5 to 13.3+/-1.9 nm/mm, P < 0.05, and OHPr/Cr from 57.4+/-11 to 35.1+/-8.4 microg/mg) and smaller changes thereafter. No significant changes were observed in the bone formation markers of osteocalcin and alkaline phosphatase. Serum iPTH, the vitamin D metabolites, and calcium concentrations fluctuated within normal, while calcium excretion increased from 0.3+/-0.1 to 1.9+/-0.4 mg/kg/24 hours, P < 0.001. In conclusion, the present study, despite its limitations of not being placebo controlled, shows possible beneficial effects of intranasal calcitonin on bone resorption and pain relief in JIA patients.     

The Analgesic Role of Calcitonin Following Osteoporotic Fracture

Osteoporosis is a systemic skeletal condition characterized by decreased bone strength with consequent increased susceptibility to bone fracture. Fragility fractures in osteoporosis are often painful and result in loss of quality of life and disability. Salmon calcitonin (SCT) is a natural hormone that may assist in the management of osteoporotic patients following fracture by reducing fracture risk and decreasing pain. SCT is an antiresorptive agent which has been shown to reduce the risk of vertebral fractures (by 36%) in postmenopausal women with osteoporosis and previous fractures, with a safety profile comparable to placebo over long-term use. Clinical evidence suggests that SCT (with either subcutaneous and intranasal delivery) is an analgesic for the acute pain following osteoporotic fracture. Pain relief with SCT occurs after 1 week or less of treatment. Associated with this pain relief, vertebral fracture patients receiving SCT have been observed to have earlier mobilization compared with those receiving a placebo. Both preclinical and clinical data suggest a central analgesic effect for SCT. The mechanism(s) by which SCT induces pain relief has (have) not been conclusively shown. Neither a direct receptor-mediated action nor an indirect endorphin-mediated effect can be ruled out. Received: 26 October 2001 / Accepted: 17 June 2002 Correspondence and offprint requests to: Stuart Silverman, MD, 8641 Wilshire Blvd, Suite 301, Beverly Hills, CA 90211, USA. e-mail: stuarts@omcresearch.org     

Intrapulmonary cystic lymphangioma: Report of a case

(Received for publication on Aug. 25, 1997; accepted on Mar. 10, 1998)     

Stanazolol—An anabolic steroid that does not influence parathyroid hormone response to hypercalcemia in postmenopausal women

Estrogen influences the calcium-induced suppressibility of parathyroid hormone (PTH) in postmenopausal women. We tested the hypothesis that parathyroid gland function is also sensitive to the anabolic steroid, stanazolol. The calcium-induced suppressibility of PTH was investigated in 11 osteoporotic postmenopausal women on two occasions, before and after 1 month's oral treatment with stanazolol. Compliance to treatment was checked by the determination of serum luteinizing hormone (LH) and testosterone. Serum intact PTH and ionized calcium were estimated before and 5, 60, and 120 minutes after I.V. calcium load. Calcium-induced PTH suppression was of a similar magnitude before and after stanazolol, although calcium increments were identical. The results imply that stanazolol—at biologically effective doses—does not affect PTH responsiveness to hypercalcemia in postmenopausal women.     

联合应用利维爱、降钙素、苯丙酸诺龙治疗去势大鼠骨质疏松症的实验研究

本实验利用去势大鼠骨质疏松模型对利维爱、降钙素、苯丙酸诺龙之间不同组合方案治疗绝经后骨质疏松症的疗效进行研究。经３个月治疗后，各治疗组的骨代谢生化指标、骨密度均有不同程度改善。本实验结果表明：利维爱和降钙素治疗绝经后骨质疏松症的疗效相似，而两者之间有正协同效应。在利维爱、降钙素的基础上加用苯丙酸诺龙之后疗效明显改善。各治疗组中以三种药物联合使用组疗效最佳，其骨代谢已基本恢复正常。全身骨密度及腰椎２～４骨密度已分别恢复至正常对照组的９４．２％和９３．６％。     

应用鲑鱼降钙素及物理疗法联合治疗原发性骨质疏松症

目的观察鲑鱼降钙素（Calcitonin，CT）和低频脉冲电磁场（low frequency transduction pulsedelectromagnetic fields）治疗联合作用在治疗原发性骨质疏松症（primary osteoporosis）中的效果，比较联合作用与单纯应用药物所产生的效果的异同。方法将存在骨质疏松性骨痛同时经DEXA骨密度仪（BMD machines）检测T值低于标准值2．0以下的老龄原发性骨质疏松症患者76人随机分为两组：①单纯应用鲑鱼降钙素组（36人）；②联合应用药物及低频电磁场组（36人），两组同时每日给予钙而奇D600片1粒，CT按每日肌肉注射50IU，10d后改为隔日肌注50IU连续应用2个月，低频电磁场治疗采用天津金希统公司生产的XT2000B型OP治疗仪，频率为20～40Hz，每天治疗20min，共治疗30d，6个月后复查骨密度。结果两组均取得较好的镇痛效果（分别为84％和97％），同时骨密度均有所增加。结论联合治疗能够更进一步增加腰椎骨密度，在镇痛方面也能取得更好的效果。     

Intranasal Delivery of PEGylated Salmon Calcitonins: Hypocalcemic Effects in Rats

To evaluate the hypocalcemic effect of polyethylene gtycol-conjugated salmon calcitonins (PEG-sCT) in rats, mono-PEGylated sCTs (mono-PEG-sCTs) and unmodified sCT were administered via the intranasal route and serum calcium levels were measured by colorimetric assay using o-cresolphthalein. Mono-PEG-sCTs were prepared with different sizes of succinimidyl succinate monomethoxy PEG molecules (PEG_2K, PEG_5K, PEG_12K) and characterized by HPLC and MALDI-TOF mass spectrometry. Nasal instillation of mono-PEG_2K-sCT at a dose of 2 IU/kg resulted in sustained reduction in serum calcium levels over 8 hr, with a maximum reduction (% max_d) of 13% after 6 hr of application. Whereas unmodified sCT showed a transient decrease in serum calcium levels with the maximum reduction (5%) observed after 30 min of administration. The overall reductions in serum calcium levels expressed as the net change in AUC relative to control in 8 hr were 11.9 ± 0.2, 4.6 ± 0.7, and 2.6 ± 0.7% for mono-PEG_2K-, mono-PEG_5K-, and mono-PEG_12K-sCT, respectively, compared to 3.2 ± 0.6% for unmodified sCT. The relative bioavailability of nasally administered 2 IU/kg of mono-PEG_2K-sCT was approximately 4-fold higher than nasally administrated unmodified sCT, and the absolute bioavailability was approximately 91% of intravenously injected sCT in 8 hr. It can be concluded that the intranasal absorption of mono-PEG-sCTs was inversely related to the molecular weights of the PEG attached. Of the PEGylated sCTs examined, mono-PEG_2K-sCT showed the most pronounced hypocalcemic effect. Therefore the intranasal application would probably be an alternative route of administration for mono-PEG-sCTs in achieving sustained calcium-lowering effects.     

Salmon calcitonin in the prevention of bone loss at perimenopause

The objective of this study was to determine whether intranasal salmon calcitonin prevents physiological bone loss at perimenopause. A double-blind study of 120 perimenopausal women without present or past disease or medication that could affect bone metabolism were studied. The subjects were randomized in two groups and provided with nasal spray bottles containing either placebo (excipient only) or active compound (excipient plus 50 international units (IU) salmon calcitonin per dose). Subjects took one puff from the nasal spray in each nostril every morning. All subjects took one soluble tablet of calcium (1000 mg) per day. Serum biochemistry, dual-energy X-ray absorptiometry of lumbar spine and proximal femur, quantitative computed tomography of lumbar spine, and single photon attenuation of forearm were used to evaluate bone mineral density (BMD). There were no differences in demographic characteristics or hormone status at entry. No fractures were recorded during the study period. Serum calcium increased and serum dihydroxyvitamin D and osteocalcin decreased in both groups. There was no difference in biochemical parameters between the groups. The BMD of upper femur did not change during the study, but it was decreased in the lumbar spine in both groups. The mineral content of distal radius increased in both groups. In conclusion, nasal salmon calcitonin, 100 IU daily, has no protective effect on bone mass and does not modify bone metabolism at perimenopause.     

阿仑膦酸钠和鲑鱼降钙素对骨质疏松骨床中假体骨整合影响的对比研究

目的探讨阿仑膦酸钠(ALO)和鲑鱼降钙素(CT)两种药物促进假体骨整合作用效果的差异,为临床药物的选择应用提供参考。方法将40只雌性SD大鼠随机分为四组(A,B,C,D组),每组10只。切除B、C、D组大鼠卵巢建立骨质疏松(OP)模型(骨密度降幅20%),A组行假手术做为对照。随后在大鼠的胫骨平台植入羟基磷灰石假体,术后C、D组分别给予皮下注射CT(5IU/kg/d)和口服ALO(7mg/kg/w)各12周,A、B组做药物干预的对照组。所有大鼠在处死前,行体内荧光染色。处死后取带假体的胫骨制备成薄片,运用骨组织计量学检测手段,观察假体周围的骨量和测量假体的骨结合率。结果(1)ALO和CT两者均能促进假体周围成骨,增加骨量,显著提高骨-假体界面骨结合率至63.7%和45.7%,较OVX组骨整合比率分别提高近1～2倍,但阿仑膦酸钠促进假体周围成骨与促进骨整合较鲑鱼降钙素作用更为显著(P0.05),骨结合率增加18%;(2)阿仑膦酸钠和鲑鱼降钙素组大鼠腰椎BMD均提高,分别从(0.081±0.009)g/cm2和(0.078±0.009)g/cm2提至(0.116±0.008)g/cm2和(0.109±0.010)g/cm2。而且,阿仑膦酸钠的效果较降钙素更为明显。结论骨质疏松条件下,全身给予阿仑膦酸钠和鲑鱼降钙素均可增强假体周围成骨及骨量,有效促进假体的骨整合,但与鲑鱼降钙素相比,阿仑膦酸钠作用更为明显。