Calcitonin for Treating Acute and Chronic Pain of Recent and Remote Osteoporotic Vertebral Compression Fractures: A Systematic Review and Meta Analysis
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Background: Vertebral collapse is one of the most common fractures associated with osteoporosis. The subsequent back pain may be severe and often requires medications and bed rest to control pain and improve mobilization. Recent studies have suggested the use of calcitonin as an initial and adjunctive treatment for severe, unrelenting back pain secondary to an osteoporotic vertebral compression fracture (OVCF), as it exhibits known analgesic properties and does not produce the unpleasant side effects associated with narcotics. Therefore, we sought to determine the analgesic efficacy of calcitonin for the treatment of acute or chronic back pain in stable patients sustaining a recent or remote OVCF. Methods: We searched the Cochrane Musculoskeletal Group (CMSG) specialized trial register , the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS, and other databases and conference proceedings up until June 2009. Primary study authors and pharmaceutical manufacturers were contacted, and bibliographies of relevant papers were hand searched. We included randomized, placebo, and controlled trials that evaluated the analgesic efficacy of calcitonin on pain levels in people with acute or chronic back pain attributed to OVCFs. Two reviewer’s extracted data, scored trial quality, preformed numeric calculations, and extrapolated graphical data independently. Where appropriate, we calculated mean differences, standardized mean differences, or risk ratios using a fixed or random effects model. Results: The combined results from 13 controlled trials, involving 589 patients, determined that calcitonin significantly reduced the severity of acute pain in recent OVCFs. Pain at rest was reduced as early as one week (MD -3.42; 95% CI: -3.96, -2.88) and this effect continued weekly to four weeks (MD -4.49; 95% CI: -4.96, -4.03). A similar pattern was seen for pain scores with mobility; at week 4 the difference in pain scores between groups was even more profound (SMD -5.99; 95% CI: -6.78, -5.19). When chronic back pain of a more remote OVCF was examined with patients at rest, there was no statistical difference between groups. When the same patients were assessed while mobile at six months, there was a statistically significant difference between groups (SMD -0.49; 95% CI: -0.85, -0.13; P = 0.008). Side effects were generally mild and self-limiting with enteric disturbances (47%) and flushing (32%) reported most frequently. Conclusions: Calcitonin has proven efficacy in the management of acute back pain associated with a recent OVCF and improves the quality of life by shortening time to mobilization. Although there was a slight improvement in back pain for patients with chronic pain at six months, this is unlikely to be of clinical significance. Therefore, there is no convincing evidence to support the use of calcitonin for the chronic pain associated with remote fractures of the same origin.