CALCITONIN SALMON

Apotex Corp.
Apotex Inc.

FULL PRESCRIBING INFORMATION

Prescribing Information

Rx Only

Calcitonin Salmon (synthetic origin) Nasal Spray

(Calcitonin Salmon Nasal Solution, USP)

Calcitonin is a polypeptide hormone secreted by the parafollicular cells of the thyroid gland in mammals and by the ultimobranchial gland of birds and fish.

Calcitonin salmon nasal spray is a synthetic polypeptide of 32 amino acids in the same linear sequence that is found in calcitonin of salmon origin. This is shown by the following graphic formula:

It is provided in a 2 mL or 3.7 mL fill glass bottle as a solution for nasal administration. This is sufficient medication for at least 14 doses (2 mL fill) or 30 doses (3.7 mL fill).

Active Ingredient:calcitonin salmon, 2200 USP Calcitonin Salmon Units per mL (corresponding to 200 USP Calcitonin Salmon Units per 0.09 mL spray).

Inactive Ingredients: benzalkonium chloride, hydrochloric acid (added as necessary to adjust pH), purified water and sodium chloride.

The activity of calcitonin salmon nasal spray is stated in International Units based on bioassay in comparison with the International Reference Preparation of calcitonin salmon for Bioassay, distributed by the National Institute of Biologic Standards and Control, Holly Hill, London.

Calcitonin acts primarily on bone, but direct renal effects and actions on the gastrointestinal tract are also recognized. Calcitonin salmon appears to have actions essentially identical to calcitonins of mammalian origin, but its potency per mg is greater and it has a longer duration of action.

The information below, describing the clinical pharmacology of calcitonin, has been derived from studies with injectable calcitonin. The mean bioavailability of calcitonin salmon nasal spray is approximately 3% of that of injectable calcitonin in normal subjects and, therefore, the conclusions concerning the CLINICAL PHARMACOLOGY of this preparation may be different.

The actions of calcitonin on bone and its role in normal human bone physiology are still not completely elucidated, although calcitonin receptors have been discovered in osteoclasts and osteoblasts.

Single injections of calcitonin cause a marked transient inhibition of the ongoing bone resorptive process. With prolonged use, there is a persistent, smaller decrease in the rate of bone resorption. Histologically, this is associated with a decreased number of osteoclasts and an apparent decrease in their resorptive activity. In vitro studies have shown that calcitonin salmon causes inhibition of osteoclast function with loss of the ruffled osteoclast border responsible for resorption of bone. This activity resumes following removal of calcitonin salmon from the test system. There is some evidence from the in vitro studies that bone formation may be augmented by calcitonin through increased osteoblastic activity.

Animal studies indicate that endogenous calcitonin, primarily through its action on bone, participates with parathyroid hormone in the homeostatic regulation of blood calcium. Thus, high blood calcium levels cause increased secretion of calcitonin which, in turn, inhibits bone resorption. This reduces the transfer of calcium from bone to blood and tends to return blood calcium towards the normal level. The importance of this process in humans has not been determined. In normal adults, who have a relatively low rate of bone resorption, the administration of exogenous calcitonin results in only a slight decrease in serum calcium in the limits of the normal range. In normal children and in patients with Paget’s disease in whom bone resorption is more rapid, decreases in serum calcium are more pronounced in response to calcitonin.

Bone biopsy and radial bone mass studies at baseline and after 26 months of daily injectable calcitonin indicate that calcitonin therapy results in formation of normal bone.

Osteoporosis is a disease characterized by low bone mass and architectural deterioration of bone tissue leading to enhanced bone fragility and a consequent increase in fracture risk as patients approach or fall below a bone mineral density associated with increased frequency of fracture. The most common type of osteoporosis occurs in postmenopausal females. Osteoporosis is a result of a disproportionate rate of bone resorption compared to bone formation which disrupts the structural integrity of bone, rendering it more susceptible to fracture. The most common sites of these fractures are the vertebrae, hip, and distal forearm (Colles' fractures). Vertebral fractures occur with the highest frequency and are associated with back pain, spinal deformity and a loss of height.

Calcitonin salmon nasal spray, given by the intranasal route, has been shown to increase spinal bone mass in postmenopausal women with established osteoporosis but not in early postmenopausal women.

In two clinical studies designed to evaluate the pharmacodynamic response to calcitonin salmon nasal spray, administration of 100 to 1600 International Units to healthy volunteers resulted in rapid and sustained small decreases (but still within the normal range) in both total serum calcium and serum ionized calcium. Single doses greater than 400 International Units did not produce any further biological response to the drug. The development of hypocalcemia has not been reported in studies in healthy volunteers or postmenopausal females.

Studies with injectable calcitonin show increases in the excretion of filtered phosphate, calcium, and sodium by decreasing their tubular reabsorption. Comparable studies have not been carried out with calcitonin salmon nasal spray.

Some evidence from studies with injectable preparations suggest that calcitonin may have significant actions on the gastrointestinal tract. Short-term administration of injectable calcitonin results in marked transient decreases in the volume and acidity of gastric juice and in the volume and the trypsin and amylase content of pancreatic juice. Whether these effects continue to be elicited after each injection of calcitonin during chronic therapy has not been investigated. These studies have not been conducted with calcitonin salmon nasal spray.

The bioavailability of calcitonin salmon nasal spray relative to intramuscular administration is between 3 and 5%. Calcitonin salmon nasal spray is absorbed by the nasal mucosa with a mean T_max of about 13 minutes. The terminal half-life of calcitonin salmon has been calculated to be around 18 minutes and no evidence of accumulation was observed with multiple dosing. Plasma exposure was higher following administration of 400 International Units nasal spray compared to that after 200 International Units dose. As is the case with other polypeptide hormones, there is very little value in monitoring plasma levels of salmon calcitonin since these are not directly predictive of the therapeutic response. Hence, calcitonin salmon activity should be evaluated by using clinical parameters of efficacy.

Calcitonin salmon nasal spray is indicated for the treatment of postmenopausal osteoporosis in females greater than 5 years postmenopause with low bone mass relative to healthy premenopausal females. Calcitonin salmon nasal spray should be reserved for patients who refuse or cannot tolerate estrogens or in whom estrogens are contraindicated. Use of calcitonin salmon nasal spray is recommended in conjunction with an adequate calcium (at least 1000 mg elemental calcium per day) and vitamin D (400 International Units per day) intake to retard the progressive loss of bone mass. The evidence of efficacy is based on increases in spinal bone mineral density observed in clinical trials.

Two randomized, placebo-controlled trials were conducted in 325 postmenopausal females (227 calcitonin salmon nasal spray treated and 98 placebo-treated) with spinal, forearm or femoral bone mineral density (BMD) at least one standard deviation below normal for healthy premenopausal females. These studies conducted over two years demonstrated that 200 International Units daily of calcitonin salmon nasal spray increases lumbar vertebral BMD relative to baseline and relative to placebo in osteoporotic females who were greater than 5 years postmenopause. Calcitonin salmon nasal spray produced statistically significant increases in lumbar vertebral BMD compared to placebo as early as six months after initiation of therapy with persistence of this level for up to 2 years of observation.

No effects of calcitonin salmon nasal spray on cortical bone of the forearm or hip were demonstrated. However, in one study, BMD of the hip showed a statistically significant increase compared with placebo in a region composed of predominantly trabecular bone after one year of treatment changing to a trend at 2 years that was no longer statistically significant. 

Clinical allergy to calcitonin salmon.

Because calcitonin is a polypeptide, the possibility of a systemic allergic reaction exists. A few cases of serious allergic-type reactions have been reported in patients receiving calcitonin salmon nasal spray, including cases of anaphylaxis and anaphylactic shock. With injectable calcitonin salmon there have been a few reports of serious allergic-type reactions (e.g., bronchospasm, swelling of the tongue or throat, anaphylactic shock), including very rare reports of death attributed to anaphylaxis. The usual provisions should be made for the emergency treatment of such a reaction should it occur. Allergic reactions should be differentiated from generalized flushing and hypotension.

For patients with suspected sensitivity to calcitonin, skin testing should be considered prior to treatment utilizing a dilute, sterile solution of calcitonin salmon injection. Physicians may wish to refer patients who require skin testing to an allergist. A detailed skin testing protocol is available from the Customer Service department of Apotex Corp. (1-877-4-APOTEX).

Formal studies designed to evaluate drug interactions with calcitonin salmon have not been done. No drug interaction studies have been performed with calcitonin salmon nasal spray ingredients.

Concomitant use of calcitonin and lithium may lead to a reduction in plasma lithium concentrations due to increased urinary clearance of lithium. The dose of lithium may need to be adjusted. 

The effects of prior use of diphosphonates in postmenopausal osteoporosis patients have not been assessed; however, in patients with Paget's disease, prior diphosphonate use appears to reduce the anti-resorptive response to calcitonin salmon nasal spray.

Periodic nasal examinations with visualization of the nasal mucosa, turbinates, septum and mucosal blood vessel status are recommended.

The development of mucosal alterations or transient nasal conditions occurred in up to 9% of patients who received calcitonin salmon nasal spray and in up to 12% of patients who received placebo nasal spray in studies in postmenopausal females. The majority of patients (approximately 90%) in whom nasal abnormalities were noted also reported nasally related complaints/symptoms as adverse events. Therefore, a nasal examination should be performed prior to start of treatment with nasal calcitonin and at any time nasal complaints occur.

In all postmenopausal patients treated with calcitonin salmon nasal spray, the most commonly reported nasal adverse events included rhinitis (12%), epistaxis (3.5%), and sinusitis (2.3%).  Smoking was shown not to have any contributory effect on the occurrence of nasal adverse events. One patient (0.3%) treated with calcitonin salmon nasal spray who was receiving 400 International Units daily developed a small nasal wound. In clinical trials in another disorder (Paget's disease), 2.8% of patients developed nasal ulcerations.

If severe ulceration of the nasal mucosa occurs, as indicated by ulcers greater than 1.5 mm in diameter or penetrating below the mucosa, or those associated with heavy bleeding, calcitonin salmon nasal spray should be discontinued. Although smaller ulcers often heal without withdrawal of calcitonin salmon nasal spray, medication should be discontinued temporarily until healing occurs.

Careful instructions on pump assembly, priming the pump, and nasal introduction of calcitonin salmon nasal spray should be given to the patient. Although instructions for patients are supplied with individual bottles, procedures for use should be demonstrated to each patient. Patients should notify their physician if they develop significant nasal irritation.

Patients should be advised of the following:

• Store new, unopened bottles in the refrigerator between 2° to 8°C (36° to 46°F).
• Protect the product from freezing.
• Before priming the pump and using a new bottle, allow it to reach room temperature.
• Store bottle in use at room temperature 20° to 25°C (68° to 77°F) in an upright position, for up to 30 days (2 mL fill) or 35 days  (3.7 mL fill). Each bottle contains at least 14 doses (2 mL fill) or 30 doses  (3.7 mL fill).
• See DOSAGE AND ADMINISTRATION , Priming (Activation) of Pump for complete instructions on priming the pump and administering calcitonin salmon nasal spray. You should keep track of the number of doses used from the bottle. After 14 doses (2 mL fill) or 30 doses (3.7 mL fill), each spray may not deliver the correct amount of medication, even if the bottle is not completely empty.

An increased incidence of nonfunctioning pituitary adenomas has been observed in one-year toxicity studies in Sprague-Dawley and Fischer 344 Rats administered (subcutaneously) calcitonin salmon at dosages of 80 International Units per kilogram per day (16 to 19 times the recommended human parenteral dose and about 130 to 160 times the human intranasal dose based on body surface area). The findings suggest that calcitonin salmon reduced the latency period for development of pituitary adenomas that do not produce hormones, probably through the perturbation of physiologic processes involved in the evolution of this commonly occurring endocrine lesion in the rat. Although administration of calcitonin salmon reduces the latency period of the development of nonfunctional proliferative lesions in rats, it did not induce the hyperplastic/neoplastic process.

Calcitonin salmon was tested for mutagenicity using Salmonella typhimurium (5 strains) and Escherichia coli (2 strains), with and without rat liver metabolic activation, and found to be non-mutagenic. The drug was also not mutagenic in a chromosome aberration test in mammalian V79 cells of the Chinese Hamster in vitro.

Urine sediment abnormalities have not been reported in ambulatory volunteers treated with calcitonin salmon nasal spray. Coarse granular casts containing renal tubular epithelial cells were reported in young adult volunteers at bed rest who were given injectable calcitonin salmon to study the effect of immobilization on osteoporosis. There was no evidence of renal abnormality and the urine sediment became normal after calcitonin was stopped. Periodic examinations of urine sediment should be considered.

Category C

Calcitonin salmon has been shown to cause a decrease in fetal birth weights in rabbits when given by injection in doses 8 to 33 times the parenteral dose and 70 to 278 times the intranasal dose recommended for human use based on body surface area. 

Since calcitonin does not cross the placental barrier, this finding may be due to metabolic effects on the pregnant animal. There are no adequate and well-controlled studies in pregnant women with calcitonin salmon. Calcitonin salmon nasal spray is not indicated for use in pregnancy.

It is not known whether this drug is excreted in human milk. As a general rule, nursing should not be undertaken while a patient is on this drug since many drugs are excreted in human milk. Calcitonin has been shown to inhibit lactation in animals.

There are no data to support the use of calcitonin salmon nasal spray in children. Disorders of bone in children referred to as idiopathic juvenile osteoporosis have been reported rarely. The relationship of these disorders to postmenopausal osteoporosis has not been established and experience with the use of calcitonin in these disorders is very limited.

In one large multicenter,  double-blind, randomized clinical study of calcitonin salmon nasal spray, 279 patients were less than 65 years old, while 467 patients were 65 to 74 years old and 196 patients were 75 and over. Compared to subjects less than 65 years old, the incidence of nasal adverse events (rhinitis, irritation, erythema, and excoriation) was higher in patients over the age of 65, particularly those over the age of 75. Most events were mild in intensity. Other reported clinical experience has not identified differences in responses between the elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out.

The incidence of adverse reactions reported in studies involving postmenopausal osteoporotic patients chronically exposed to calcitonin salmon nasal spray (N=341) and to placebo nasal spray (N=131) and reported in greater than 3% of calcitonin salmon nasal spray treated patients are presented below in the following table. Most adverse reactions were mild to moderate in severity. Nasal adverse events were most common with 70% mild, 25% moderate, and 5% severe in nature (placebo rates were 71% mild, 27% moderate, and 2% severe).

* Symptom of nose includes: nasal crusts, dryness, redness or erythema, nasal sores, irritation, itching, thick feeling, soreness, pallor, infection, stenosis, runny/blocked, small wound, bleeding wound, tenderness, uncomfortable feeling and sore across bridge of nose.

In addition, the following adverse events were reported in fewer than 3% of patients during chronic therapy with calcitonin salmon nasal spray^{. Adverse events reported in 1% to 3% of patients are identified with an asterisk (*). The remainder occurred in less than 1% of patients. Other than flushing, nausea, possible allergic reactions, and possible local irritative effects in the respiratory tract, a relationship to calcitonin salmon nasal spray has not been established.}

Body as a Whole – General Disorders

influenza-like symptoms*, fatigue*, edema (facial, peripheral, and generalized), fever

Integumentary

erythematous rash*, skin ulceration, eczema, alopecia, pruritus, increased sweating

Musculoskeletal/Collagen

arthrosis*, myalgia*, arthritis, polymyalgia rheumatica, stiffness

Respiratory/Special Senses

sinusitis*, upper respiratory tract infection*, bronchospasm*, pharyngitis, bronchitis, pneumonia, coughing, dyspnea, taste perversion, parosmia, nasal congestion, sneezing, allergic rhinitis, nasal odor, mucosal excoriation, rhinitis ulcerative

Cardiovascular

hypertension*, angina pectoris*, tachycardia, palpitation, bundle branch block, myocardial infarction

Gastrointestinal

dyspepsia*, constipation*, abdominal pain*, nausea*, diarrhea*, vomiting, flatulence, increased appetite, gastritis, dry mouth

Liver/Metabolic

cholelithiasis, hepatitis, thirst, weight increase

Endocrine

goiter, hyperthyroidism

Urinary System

cystitis*, pyelonephritis, hematuria, renal calculus

Central and Peripheral Nervous System

dizziness*, paresthesia*, vertigo, migraine, neuralgia, agitation, tremor

Hearing/Vestibular

tinnitus, hearing loss, earache

Vision

abnormal lacrimation*, conjunctivitis*, blurred vision, vitreous floater, visual disturbance

Vascular

flushing, cerebrovascular accident, thrombophlebitis

Hematologic/Resistance Mechanisms

lymphadenopathy*, infection*, anemia

Psychiatric

depression*, insomnia, anxiety, anorexia

Immune System Disorders

hypersensitivity, anaphylaxis and anaphylactic shock

Common adverse reactions associated with the use of injectable calcitonin salmon occurred less frequently in patients treated with calcitonin salmon nasal spray than in those patients treated with injectable calcitonin. Nausea, with or without vomiting, which occurred in 1.8% of patients treated with the nasal spray (and 1.5% of those receiving placebo nasal spray) occurs in about 10% of patients who take injectable calcitonin salmon. Flushing, which occurred in less than 1% of patients treated with the nasal spray, occurs in 2% to 5% of patients treated with injectable calcitonin salmon. Although the administered dosages of injectable and nasal spray calcitonin salmon are comparable (50 to 100 units daily of injectable versus 200 units daily of nasal spray), the nasal dosage form has a mean bioavailability of about 3% (range 0.3% to 30.6%) and therefore provides less drug to the systemic circulation, possibly accounting for the decrease in frequency of adverse reactions.

The collective foreign marketing experience with calcitonin salmon nasal spray does not show evidence of any notable difference in the incidence profile of reported adverse reactions when compared with that seen in the clinical trials.

No instances of overdose with calcitonin salmon nasal spray have been reported and no serious adverse reactions have been associated with high doses. There is no known potential for drug abuse for calcitonin salmon.

Single doses of calcitonin salmon nasal spray up to 1600 International Units, doses up to 800 International Units per day for three days and chronic administration of doses up to 600 International Units per day have been studied without serious adverse effects. A dose of 1000 International Units of calcitonin salmon injectable solution given subcutaneously may produce nausea and vomiting. A dose of calcitonin salmon injectable solution of 32 International Units per kg per day for one or two days demonstrated no additional adverse effects.

There have been no reports of hypocalcemic tetany. However, the pharmacologic actions of calcitonin salmon nasal spray suggest that this could occur in overdose. Therefore, provisions for parenteral administration of calcium should be available for the treatment of overdose.

The recommended dose of calcitonin salmon nasal spray in postmenopausal osteoporotic females is one spray (200 USP Calcitonin Salmon Units) per day administered intranasally, alternating nostrils daily.

Drug effect may be monitored by periodic measurements of lumbar vertebral bone mass to document stabilization of bone loss or increases in bone density. Effects of calcitonin salmon nasal spray on biochemical markers of bone turnover have not been consistently demonstrated in studies in postmenopausal osteoporosis. Therefore, these parameters should not be solely utilized to determine clinical response to calcitonin salmon nasal spray therapy in these patients.

Before the first dose and administration, calcitonin salmon nasal spray should be at room temperature. To prime the pump, the bottle should be held upright and the two white side arms of the pump depressed toward the bottle until a full spray is produced. The pump is primed once the first full spray is emitted. To administer, the nozzle should be carefully placed into the nostril with the head in the upright position, and the pump firmly depressed toward the bottle. The pump should not be primed before each daily dose.

Calcitonin Salmon (synthetic origin) Nasal Spray (Calcitonin Salmon Nasal Solution, USP) isavailable as a metered dose clear solution in a 2 mL or 3.7 mL fill clear glass bottle. It is availablein a dosage strength of 200 USP Calcitonin Salmon Units per spray (0.09 mL/spray). The pump,following priming, will deliver 0.09 mL of solution. Calcitonin Salmon (synthetic origin) Nasal Spray(Calcitonin Salmon Nasal Solution, USP) contains 2200 USP Calcitonin Salmon Units/mLcalcitonin salmon and is provided in an individual box containing one glass bottle with attachedpump (2 mL fill: NDC 60505-0823-0; 3.7 mL fill: NDC 60505-0823-6).

Store and Dispense

Store unopened bottle in refrigerator between 2° to 8°C (36° to 46°F). Protect from freezing. Store bottle in use at room temperature 20° to 25°C (68° to 77°F) in an upright position, for up to 30 days (2 mL fill) or 35 days (3.7 mL fill). Each bottle contains at least 14 doses (2 mL fill) or 30 doses (3.7 mL fill).

July 2013

Information for the Patient

Calcitonin Salmon (synthetic origin) Nasal Spray

(Calcitonin Salmon Nasal Solution USP)

What is calcitonin salmon nasal spray?

Calcitonin salmon nasal spray is a medication used for the treatment of osteoporosis after menopause (postmenopausal osteoporosis) in women more than 5 years after menopause with low bone mass who refuse or cannot tolerate estrogens, or in whom estrogens are not an option.

Patients who use calcitonin salmon nasal spray should be sure to ingest adequate amounts of calcium and vitamin D along with therapy.

How much calcium and vitamin D do I need each day?

When taking calcitonin salmon nasal spray, it is recommended that you get at least 1000 mg of calcium and 400 International Units of vitamin D each day.  Check with your doctor or healthcare provider to see if you are getting enough calcium and vitamin D in your diet.  If not, he or she may recommend that you start taking calcium and vitamin D supplements.

What is osteoporosis after menopause?  What causes it?

Postmenopausal osteoporosis is a condition associated with frail, brittle bones.  It usually occurs when "old" bone cells are removed from bones faster than they can be replaced by "new" bone cells.  As a result, bones get weak and may become susceptible to fractures.

Osteoporosis occurs most frequently in women who have gone through menopause.  At menopause, a woman’s body goes through many changes, including a substantial decrease in the amount of estrogen produced.  Estrogen in your body helps keep bones strong - without it, they may become weak.

Postmenopausal osteoporosis begins without notice; however, over time symptoms develop such as:

• Curved spine
• Rounded shoulders
• Loss of height

Untreated, postmenopausal osteoporosis can be painful and disabling.  Some women with postmenopausal osteoporosis suffer from broken hips and fractured wrists.  Fortunately, osteoporosis after menopause is treatable.  Your doctor or healthcare provider can prescribe a medication, like calcitonin salmon nasal spray, to treat your condition.

How does calcitonin salmon nasal spray work?

The active ingredient in calcitonin salmon nasal spray is calcitonin, a man-made protein similar to one found in people, other mammals, and some types of fish and birds.

The way calcitonin affects bone is still being studied, but it is believed to work in the following ways:

• Calcitonin reduces the activity of osteoclasts [AHS-tee-oh-clasts], the cells that remove "old" bone
• Because bone building continues while bone removal is slowed down, the result is an increase in bone mass

When you spray calcitonin salmon nasal spray into your nostril, it is rapidly absorbed by the blood vessels lining your nasal passages.  It then travels into your bloodstream and on to your bones where it works to stop bone loss and helps your bones become stronger.

How do I use calcitonin salmon nasal spray?

The recommended dose of calcitonin salmon nasal spray is one spray daily in alternated nostrils- unless directed otherwise by your healthcare provider.  Start with a spray in the left nostril on your first day, followed by a spray in the right nostril on the second day.  Continue to alternate nostrils every day.  There are at least 14 “doses” (2 mL fill) or 30 "doses" (3.7 mL fill) of calcitonin salmon nasal spray in each bottle.  You should keep track of the number of doses used from the bottle.  After 14 doses (2 mL fill) or 30 doses (3.7 mL fill), each spray may not deliver the correct amount of medication, even if the bottle is not completely empty.

Who should not take calcitonin salmon nasal spray?

Calcitonin salmon nasal spray should not be used by patients who are allergic to the protein calcitonin salmon, or by women who are pregnant or nursing.

You should be aware of these warnings and precautions when taking calcitonin salmon nasal spray.

• No formal studies designed to test drug interactions with calcitonin salmon have been done; however, no drug interactions have been observed with the use of calcitonin salmon nasal spray. You should inform your doctor and pharmacist about the other prescription and nonprescription medications you are taking.
• In clinical studies, nasal symptoms occurred in approximately 9% of postmenopausal patients taking calcitonin salmon nasal spray. For this reason, it is recommended that a nasal examination be performed prior to the start of treatment and at any time nasal complaints occur.
• Rare instances of nasal ulceration have occurred with calcitonin salmon nasal spray.  In some cases, your doctor may decide to temporarily discontinue treatment with calcitonin salmon nasal spray until symptoms subside.
• Because calcitonin salmon is a protein, the possibility of a systemic allergic reaction exists. Patients who are allergic to calcitonin salmon should not use calcitonin salmon nasal spray.
• Calcitonin salmon nasal spray is safe to use in elderly patients. A slight increase in nasal symptoms has been observed in patients over 65 years of age, however the symptoms are usually mild. No other unusual side effects have been seen in patients over 65 years of age.

Possible side effects

Most patients tolerate treatment with calcitonin salmon nasal spray very well; however, like all prescription drugs, calcitonin salmon nasal spray may cause some side effects in some people.  These side effects are usually mild and generally do not lead to discontinuation of treatment with calcitonin salmon nasal spray.  The most commonly reported side effects are:

• Nasal symptoms such as runny nose, crusting or nasal bleeding
• Back/joint pain
• Headache

Anytime you have a medical problem you think may be related to calcitonin salmon nasal spray, talk to your doctor or healthcare provider.

Call your doctor for medical advice about side effects. You may report the side effect to FDA at 1-800-FDA-1088

Your doctor or pharmacist can demonstrate how to prime and use calcitonin salmon nasal spray.  In addition, detailed directions can be found on the reverse side of this insert.  Please read them carefully before using the spray.

This medication is prescribed for a particular condition.  Do not use it for another condition or give the drug to others.  Keep calcitonin salmon nasal spray and all medicines out of reach of children.  This insert provides a summary of information about calcitonin salmon nasal spray.  If you have any questions or concerns about either calcitonin salmon nasal spray or osteoporosis, talk to your doctor.  In addition, talk to your pharmacist or other healthcare provider.

PATIENT'S INSTRUCTIONS FOR USE

Calcitonin Salmon Nasal Spray

(Calcitonin Salmon Nasal Solution USP)

One Spray, Once a Day

BEFORE USING CALCITONIN SALMON NASAL SPRAY

This package contains one bottle of calcitonin salmon nasal spray with attached pump.

Important Facts About Your Medication:

• The bottle contains the proper amount of medication - be aware that the entire bottle will not be filled with liquid
• Before opening your medication bottles, keep it in your refrigerator at 2°-8°C (36°- 46°F).  Do not freeze
• After opening a new medication bottle, keep it at room temperature, 20°-25°C (68°-77°F) in an upright position

HOW TO USE CALCITONIN SALMON NASAL SPRAY

1. Remove the clear plastic dust cap and the blue safety clip from the nasal spray pump (Figure 1).  The safety clip prevents the accidental discharge of the spray in your pocket or purse.
Priming a New Bottle 2. To ensure proper delivery of medication, a newly opened bottle must be primed before you use it for the first time.  Holding the bottle upright with your index and middle fingers on the two shoulder areas of the pump, and your thumb on the bottom of the bottle, press the shoulders down fully until you see a full spray (Figure 2).  Now the nasal spray is ready for use. Do not re-prime the pump before each daily use because this will waste your medication.
Using the Medication 3. The recommended dose of calcitonin salmon nasal spray is one spray once a day in one nostril.  Keep your head upright and carefully place the nozzle in one nostril. Tilt the bottle until it is in a straight line with the nasal passage (Figure 3). Firmly press down on the pump once to spray the medication into your nose.  It is not necessary to inhale while this is being done.  Please note:  Because the mist is so fine, you may not feel it inside your nose.  Also, some medication may drip out of your nose.  However, in either case, the medication is absorbed.  IMPORTANT:  Do not "test" the spray unit or prime it before you use your daily dose because this will waste your medication.
Cleaning the Pump 4. Once or twice a week, wipe the nozzle with a clean, damp cloth.  Dry the nozzle before replacing the protective cap.
Storing the Unit 5. Replace the blue safety clip, then replace the protective cap on the nasal spray unit (Figure 4).  Be careful not to depress the pump while this is being done.  Once the pump is primed, the unit must be kept at room temperature 20°-25°C (68°-77°F) in the upright position until the medication is finished.

IMPORTANT

• Do not refrigerate the unit between doses.
• Do not store the unit on its side.

Bottles left at room temperature (opened or unopened) for more than 30 days (2 mL fill) or 35 days (3.7 mL fill) must be discarded.

Refrigerated bottles are good until the expiration date stamped on the bottle and box.

Alternate Nostrils Daily

The first day, start with one spray in the left nostril.  The next day, use one spray in the right nostril, and so on.

It is important to receive the correct daily amount of calcium and vitamin D, as directed by your healthcare provider.

IMPORTANT

• Use calcitonin salmon nasal spray daily. To ensure proper treatment, it is important to use your calcitonin salmon nasal spray daily even if you have no symptoms of postmenopausal osteoporosis.

What is the Correct Dose of Calcitonin Salmon Nasal Spray?

A single spray of calcitonin salmon nasal spray contains one daily dose, which is 200 USP Calcitonin Salmon Units of calcitonin salmon.  The fine mist is actually 0.09 mL (milliliter) of solution.  Your bottle of calcitonin salmon nasal spray contains at least 14 doses (2 mL fill) or 30 doses (3.7 mL fill).  Priming the pump as described in step 2 does not alter the total number of doses available in a bottle of calcitonin salmon nasal spray.  The bottle need only be primed once.  Do not reprime or "test spray" your bottle before you use your daily dose of calcitonin salmon nasal spray.  This will waste your medication.

Please see your healthcare provider for complete product information for calcitonin salmon nasal spray.

July 2013

PACKAGE CARTON LABEL

APOTEX CORP. NDC 60505-0823-0

Calcitonin Salmon (synthetic origin) Nasal Spray
(Calcitonin Salmon Nasal Solution, USP)

Rx

14 dose bottle

2200 USP Calcitonin Salmon Units/mL

(200 USP Calcitonin Salmon Units/spray)

FOR INTRANASAL USE ONLY

REFRIGERATE UNTIL OPENED