Osteoporosis Treatments Compared to Assess Effects on Bone Mineral Density

Osteoporosis. Computer artwork of the trabeculae in the cancellous (spongy) bone tissue affected by osteoporosis. The cancellous tissue fills the interior of the bones and in osteoporosis its density decreases, increasing the brittleness of the bones and the probability of fractures. Osteoporosis usually affects women, above all after the menopause, because their ovaries no longer produce oestrogen hormones which help to maintain bone mass.
The network meta-analysis compared the effects of 9 osteoporosis drugs on BMD.

Denosumab appears to have the biggest effect on bone mineral density (BMD) in postmenopausal women with osteoporosis, according to the findings of a systematic review and network meta-analysis recently published in the Journal of Orthopaedic Surgery and Research.

While osteoporosis is common in postmenopausal women, trials directly comparing pharmaceutical agents used to treat this condition are lacking. In an effort to provide additional clinical evidence, the study authors conducted a network meta-analysis that compared the effects of 9 osteoporosis drugs on BMD in postmenopausal osteoporosis patients.

A total of 64 randomized clinical trials (N=82,732) were included in the analysis. The mean follow-up was reported to be 29.7±19.6 months.

Findings revealed that spine BMD was highest in patients receiving denosumab (standard mean difference [SMD], -0.22; standard error [SE], 3.38; 95% CI, -6.84, 6.40), followed by pamidronate (SMD, -5.66; SE, 2.64; 95% CI, -10.83, -0.50) and zoledronate (SMD, -10.70; SE, 2.87; 95% CI, -16.33, -5.07).

Denosumab was also found to be associated with a higher hip BMD (SMD, -0.26; SE, 3.18; 95% CI, -6.50, 5.98) as well as a higher femur BMD (SMD, 0.10; SE, 2.09; 95% CI, -4.00, 4.20) compared with other agents.

Higher hip BMDs were also observed in patients who received alendronate (SMD, -17.03; SE, 3.19; 95% CI, -23.29, -10.78) and ibandronate (SMD, -17.25; SE, 2.26; 95% CI, -21.69, -12.81). These agents were also found to be associated with higher femur BMDs (alendronate: SMD, -16.03; SE, 1.70; 95% CI, -19.37, -12.69; ibandronate: SMD, -17.00; SE, 1.68; 95% CI, -20.29, -13.71).

The study was limited by its focus on BMD effects; fracture risk reduction, adverse events, and cost were not factored into the analysis. Additionally, agents such as abaloparatide and romosozumab were not included in the investigation due to a lack of studies.

“The present investigation shows that denosumab was associated with the highest BMD of all evaluated osteoporosis drugs in selected women with postmenopausal osteoporosis,” the authors concluded. They added that future studies should assess the effect of these agents on overall fracture risk as well as other osteoporosis types. 


Migliorini F, Maffulli N, Colarossi G, Eschweiler J, Tingart M, Betsch M. Effect of drugs on bone mineral density in postmenopausal osteoporosis: a Bayesian network meta-analysis. J. Orthop. Surg. Res. Published online August 27, 2021. doi: 10.1186/s13018-021-02678-x.