Karissa A. Thal, MD; Andrew J. Foy Jr., MD; Matthew S. Nudy, MD; Eileen M. Moser, MD
Corresponding Author: Karissa A. Thal, MD; Department of Family and Community Medicine - Mount Nittany Physician Group.
Contact Email: Karissa.thal@mountnittany.org
Section: Clinical Review
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BACKGROUND: There are multiple classes of pharmacologic agents approved for treatment of osteoporosis, but their costs vary widely and systematic data on their efficacy compared to the traditional standard, bisphosphonates, for reducing fractures in post-menopausal women is lacking. The objective is to perform a systematic review and meta-analysis assessing the efficacy of denosumab compared to bisphosphonates for reducing fractures.
METHODS: Researchers selected RCTs comparing denosumab to bisphosphonates that included information on clinical and/or osteoporotic fracture events over the follow-up period. We followed the PRISMA statement for reporting systematic reviews and meta-analyses. Two-hundred seventy-four articles were identified by a literature review; 267 did not meet the inclusion criteria and were eliminated. Each clinical outcome was meta-analyzed on the log relative scale using a fixed-effects analysis. The outcomes of interest were clinical and osteoporotic fractures. A meta-regression was performed using change in bone mineral density (BMD) as the moderator variable.
RESULTS: Seven RCTs were included. Denosumab was not associated with a reduction in clinical (3.7% vs 2.6%; OR 1.12; 95% CI 0.79 – 1.61) or osteoporotic fractures (2.4% vs 1.7%; OR 1.11; 95% CI 0.71 – 1.73) compared to bisphosphonates and there is moderate confidence in this finding. There was no association between the change in BMD between denosumab and bisphosphonates and denosumab’s effect on both osteoporotic and clinical fractures.
DISCUSSION: Existing data does not support the use of the more expensive denosumab as a first-line agent over bisphosphonates for reduction of fractures in post-menopausal women with osteoporosis. One limitation in this study was each RCT was not individually powered for fracture incidences.