Comparative Effectiveness of Drug Treatments to Prevent Fragility Fractures: A Systematic Review and Network Meta-Analysis
The Journal of Clinical Endocrinology & Metabolism March 30, 2012 jc.2011-3060
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Calcium & Vitamin D 19% reduction (unknown amounts of each)
Teriparatide 70% reduction of hip fractures
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Mohammad Hassan Murad Murad.mohammad at mayo.edu , Matthew T. Drake, Rebecca J. Mullan, Karen F. Mauck, Louise M. Stuart, Melanie A. Lane, Nisrin O. Abu Elnour, Patricia J. Erwin, Ahmad Hazem, Milo A. Puhan, Tianjing Li and Victor M. Montori
Knowledge and Evaluation Research Unit (M.H.M., R.J.M., L.M.S., M.A.L., N.O.A.E., V.M.M.),
Division of Preventive Medicine (M.H.M.),
Division of Endocrinology, Diabetes, Metabolism, Nutrition (M.T.D., V.M.M.),
Division of General Internal Medicine (K.F.M.), and
Mayo Clinic Libraries (P.J.E.), Mayo Clinic, Rochester, Minnesota 55905;
Department of Internal Medicine (A.H.), University of North Dakota, Fargo, North Dakota 58102; and
Department of Epidemiology (M.A.P., T.L.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 21205
Context: Osteoporosis and osteopenia are associated with increased fracture incidence.
Objective: The aim of this study was to determine the comparative effectiveness of different pharmacological agents in reducing the risk of fragility fractures.
Data Sources: We searched multiple databases through 12/9/2011.
Study Selection: Eligible studies were randomized controlled trials enrolling individuals at risk of developing fragility fractures and evaluating the efficacy of bisphosphonates, teriparatide, selective estrogen receptor modulators, denosumab, or calcium and vitamin D.
Data Extraction: Reviewers working independently and in duplicate determined study eligibility and collected descriptive, methodological quality, and outcome data.
Data Synthesis: This network meta-analysis included 116 trials (139,647 patients; median age, 64 yr; 86% females and 88% Caucasians; median follow-up, 24 months). Trials were at low to moderate risk of bias. Teriparatide had the highest risk reduction of fractures (odds ratios, 0.42, 0.30, and 0.50 for hip, vertebral, and nonvertebral fractures, respectively) and the highest probability of being ranked first for efficacy (probabilities of 42, 49, and 79% for hip, vertebral, and nonvertebral fractures, respectively). However, differences to denosumab, zoledronate, risedronate, ibandronate, and alendronate were not statistically significant. Raloxifene and bazedoxifene were likely less effective, although these data were limited. Calcium and vitamin D were ineffective given separately but reduced the risk of hip fractures if given in combination (odds ratio, 0.81; 95% confidence interval, 0.68–0.96).
Conclusions: Teriparatide, bisphosphonates, and denosumab are most effective in reducing the risk of fragility fractures. Differences in efficacy across drugs are small; therefore, patients and clinicians need to consider their associated harms and costs.
Received November 7, 2011; Accepted March 7, 2012. Copyright © 2012 by The Endocrine Society
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- Overview Fractures and vitamin D
- Overview Osteoporosis and vitamin D
- Lowest cost osteoporosis treatment was vitamin D and Calcium – Oct 2010
- Low cost co-factors for vitamin D More than Calcium is needed for healthy bones
- Cochrane review finds that Vitamin D helps prevent fractures– downloaded Feb 2010
- Bisphosphonates 4.5 X more likely to work when vitamin D level above 33 ng – Sept 2011
- International Osteoporosis Foundation: Vitamin D is the first of three ways to make unbreakable bones – Oct 2011
- Vitamin D 2nd most recommended way to prevent next hip fracture – Nov 2010
- LTC was first
- Is it ethical to not give vitamin D in osteoporosis trials– NEJM Sept 2010