15 patients with Paget's bone disease were treated with varying schedules of porcine (3.8-157.5 MRCU/kg per wk) and/or salmon (1.5-210 MRCU/kg per wk) calcitonins over periods ranging from 4 to 24 months. All of the subjects experienced a striking decrease in serum alkaline phosphatase during the first 4 months of treatment. In six patients, however, resistance to these peptides was suggested by a subsequent elevation of alkaline phosphatase activity in spite of continued and augmented hormone administration. These rebounds in alkaline phosphatase levels correlated with the appearance of calcitonin-binding substances and neutralizing material in serum. Incubations of calcitonins-125I and sera from these six subjects resulted in the association of radioactivity with material whose behavior on chromatoelectrophoresis (6/6), sucrose density ultracentrifugation and immunoelectrophoresis (one subject) was identical with that of 7S immunoglobulin. Specific, reversible in vitro binding of salmon calcitonins-125I was observed in sera obtained from these patients 5 to 12 months after initiation of salmon calcitonin therapy. All six of these subjects' sera acquired the capacity to neutralize salmon calcitonin's hypocalcemic effect in rat bioassay. Neutralization titers correlated with maximal binding capacities, which ranged from 0.042 to 6.6 mg/liter of serum. Competitive displacement of calcitonins-125I from the sera of one patient treated with both porcine and salmon calcitonin indicated separate populations of antibodies to these hormones. In spite of return of disease activity comparable to baseline levels, 3/5 resistant subjects treated with salmon calcitonin failed to develop hypocalcemia after injection of 300-1000 MRCU of salmon calcitonin, but two of these patients developed hypocalcemia in response to the porcine hormone. The disappearance of total radioactivity from the circulation after intravenous administration of salmon calcitonin-125I was retarded and the amount of serum radioactivity precipitable in 50% (NH4)2SO4 greater in 3/3 resistant patients compared to control subjects. These observations on the incidence of significant titers of neutralizing antibodies to salmon (40%) and porcine (66%) calcitonins during their chronic (> 4 months) administration to man clearly indicate that an appraisal of this possibility be included in studies involving protracted use of these hormones.
John G. Haddad Jr., Joseph G. Caldwell