According to the International Osteoporosis Foundation, more than 200 million people worldwide suffer from osteoporosis, or insufficient regeneration of bone tissue and fragile bones. At least 40% of postmenopausal women and 15-30% of older men will sustain one or more fractures due to fragility. Osteopenia, a lesser form of bone loss, affects many millions as well, and may progress to a full osteoporosis diagnosis.

Because of the widespread nature of these disorders, and the associated risk of fractures and related health issues, many treatments have been developed. There are numerous medications and hormone treatments used to slow or prevent bone loss, each with different indications and side effect profiles. The variety of treatments and volume of related information can be difficult for physicians to sort through to find the appropriate therapy for their patients.

Comparative effectiveness research

"There are too many drugs that are used for osteoporosis," says M. Hassan Murad, M.D., an internal medicine doctor and a clinical epidemiologist in the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery. "We wanted to compare them so that patients and physicians can make informed decisions."

In order to determine which treatments work best, medical researchers conduct comparative effectiveness research, in which they collect and analyze the results of many clinical trials testing treatments for a particular disease or condition. This can be done using a complex statistical technique called network meta-analysis. The researchers then figure out which interventions consistently rise to the top as being most effective.

Dr. Murad, who also leads Mayo Clinic's Evidence-Based Practice Center, accepted the challenge of the Endocrine Society to provide the evidence to support the society's guidelines for the treatment of postmenopausal women with osteoporosis.

Evidence-based practice recommendations

His multidisciplinary team reviewed and analyzed the results from 107 randomized clinical trials that enrolled postmenopausal women with primary osteoporosis or osteopenia and evaluated different treatments to prevent hip, vertebral (back/spine) or other fractures. These studies, conducted around the world, tested one or more of the following interventions: various bisphosphonates, teriparatide, selective estrogen receptor modulators, denosumab, abaloparatide, romosozumab, estrogen with or without progesterone, calcitonin, lasofoxifene, strontium ranelate, tibolone, PTH 1-84, calcium, or vitamin D.

They found that some treatments did indeed rise to the top as most effective for halting the progression of osteoporosis and resulting bone fragility.

"The most effective treatments to prevent fractures were bisphosphonates and some newer medications: romosozumab, denosumab and teriparatide," says Dr. Murad.

It is possible that these findings could be practice changing, he says. "When physicians prescribe these medications to women with osteoporosis, they can use the results of this study to guide their choices."

The research identified several effective treatments, so Dr. Murad says, "Patients should ask about side effects and costs, as well as ease of administration – some of these drugs are injectable and some are orals."

###

The Mayo Clinic Evidence-Based Practice Center is so designated by the Agency for Healthcare Research and Quality. Recently it also became designated as a Cochrane affiliate within the Cochrane US Network. The evidence-based practice research program seeks to improve the quality, effectiveness and appropriateness of health care by synthesizing research evidence and facilitating the translation findings into clinical practice.

Related resources:

• Efficacy of Pharmacological Therapies for the Prevention of Fractures in Postmenopausal Women: A Network Meta-Analysis (full research paper, free access)
• FDA advisory committee recommends approval of romosozumab for osteoporosis (news story at Healio.com)
• Mayo Clinic Q and A: Finding the right osteoporosis medication (discusses denosumab)
• Teriparatide (drug description and related information on mayoclinic.org)
• Mayo Clinic Minute: How osteoporosis affects men

Related Articles