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Recent papers in Thorax have described the high prevalence of low bone mineral density (BMD) in individuals with cystic fibrosis1 2; these patients are at increased risk of fractures.3 4 Rib fracture pain can often be difficult to treat, despite standard analgesia such as non-steroidal anti-inflammatory drugs and opiates. Rib pain can impair sputum clearance and lead to an exacerbation of CF pulmonary disease. There are reports that calcitonin can relieve bone pain for patients with osteolytic metastases5 and osteoporotic vertebral fractures.6 Recently, we have successfully used subcutaneous calcitonin for the treatment of rib fracture pain in two patients with CF.
A 25 year old woman fractured two ribs when she was crushed in the crowd at a rock concert and a 28 year old man fractured ribs following a bout of coughing. Both patients had CF related low BMD with DEXA Z scores at the lumbar spine of –2.5 and –3.6, respectively. They had been taking long term oral prednisolone at a dose of 10 mg per day. Both patients had continuous uncontrolled pain from their fracture sites despite regular oral analgesics. The female patient was taking paracetamol 1 g qds and morphine sulphate modified release 30 mg bd; the male patient was taking paracetamol 1 g qds and ibuprofen 600 mg tds. Both patients were given courses of antibiotics as the pain was leading to an exacerbation of their CF lung disease. Subcutaneous calcitonin (salcatonin) was given in a dose of 50 units once daily. The pain completely resolved within 48 hours in both cases, and the patients were able to mobilise, perform sputum clearance, the other analgesics were withdrawn, and the chest exacerbations resolved. The calcitonin injections were continued for a total of 7 days, then stopped without recurrence of any pain. Neither patient experienced any side effects from the calcitonin.
Although calcitonin is involved in the regulation of bone turnover, the mechanism of its analgesic action is unknown. It reduces bone resorption and bone blood flow, but may also have central analgesic effects. Conversely, intravenous bisphosphonates, given to improve bone density, were associated with severe bone pain in individuals with CF.7
Pain control is essential in patients with CF and rib fractures if adequate sputum clearance is to be achieved and an acute deterioration in lung disease avoided. Calcitonin should be considered as an analgesic in this situation. Such intervention may reduce morbidity and mortality associated with rib fractures in this group of patients.
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