Comparative efficacy of bone anabolic therapies in women with postmenopausal osteoporosis: A systematic review and network meta-analysis of randomized controlled trials

Adrian V Hernandez, Faustino R Pérez-López, Alejandro Piscoya, Vinay Pasupuleti, Yuani M Roman, Priyaleela Thota, Antonio Herrera

Research output: Contribution to journalArticlepeer-review

15 Scopus citations


OBJECTIVE: To systematically evaluate the effects of bone anabolic therapies (BATs) - specifically, drug therapy with teriparatide, abaloparatide or romosozumab - on fractures, bone mineral density (BMD), and bone metabolites in postmenopausal osteoporosis.

METHODS: Six computerized engines were searched through to November 2018. We selected randomized controlled trials (RCTs) evaluating the effect of BATs on postmenopausal osteoporosis and with at least 6 months of follow-up. Controls were placebo, no treatment, or bisphosphonates. Primary outcomes were vertebral and non-vertebral fractures. Secondary outcomes were: BMD determined by dual energy X-ray absorptiometry at total hip, lumbar spine, and femoral neck; N-terminal propeptide of type I procollagen (PINP); C-terminal telopeptide of type I collagen (CTX); and severe adverse events (SAE). We followed the PRISMA guidelines for reporting, and used version 2 of the Cochrane risk-of-bias tool. Frequentist network meta-analyses were performed per outcome. Effects for dichotomous and continuous outcomes were expressed as relative risks and mean differences and their 95% confidence intervals. We used p-scores to rank best treatments per outcome.

RESULTS: Sixteen RCTs (n = 18,940) were evaluated. Mean ages ranged between 61 and 74 years, and follow-up times between 6 and 30 months. Four RCTs (n = 971) excluded patients with previous fractures. In contrast to placebo/no treatment, all BATs significantly reduced the risk of vertebral fractures, but no intervention significantly reduced the risk of non-vertebral fractures; abaloparatide ranked better than other interventions for both fracture types (p-scores: 0.95, and 0.89, respectively). All BATs significantly increased BMD at all locations in comparison with placebo/no treatment; romosozumab consistently ranked better than other interventions at all BMD locations (p-scores >0.86). Teriparatide ranked better than other interventions for increasing PINP. No differences in SAE were observed among treatments.

CONCLUSIONS: Abaloparatide, romosozumab, and teriparatide are the best treatments, respectively, to reduce vertebral/non-vertebral fractures, increase BMD, and increase bone formation.

Original languageEnglish
Pages (from-to)12-22
Number of pages11
StatePublished - Nov 2019
Externally publishedYes


  • Antibodies, Monoclonal/pharmacology
  • Bone Density/drug effects
  • Bone Density Conservation Agents/pharmacology
  • Collagen Type I/blood
  • Female
  • Humans
  • Network Meta-Analysis
  • Osteoporosis, Postmenopausal/blood
  • Osteoporotic Fractures/prevention & control
  • Parathyroid Hormone-Related Protein/pharmacology
  • Peptide Fragments/blood
  • Peptides/blood
  • Procollagen/blood
  • Randomized Controlled Trials as Topic
  • Teriparatide/pharmacology


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