Abstract
ObjectivesEmerging evidence has indicated a role for pharmacologic agents in the primary prevention of osteoporotic fracture, but have not yet been systematically reviewed for meta-analysis. We conducted a meta-analysis to evaluate the efficacy of pharmacologic interventions in reducing fracture risk and increasing bone mineral density (BMD) in postmenopausal women with osteopenia or osteoporosis but without prevalent fragility fracture. MethodThe Medline, EMBASE, and CENTRAL databases were searched from inception to September 30, 2019. Only randomized placebo-controlled trials evaluating postmenopausal women with −1.0 > bone mineral density (BMD) T-score > −2.5 (low bone mass) and those with BMD T-score ≤ −2.5 (osteoporosis) but without baseline fractures, who were receiving anti-osteoporotic agents, providing quantitative outcomes data and evaluating risk of vertebral and/or non-vertebral fragility fracture at follow-up. The PRISMA guidelines were followed, applying a random-effects model. The primary endpoint was the effect of anti-osteoporotic regimens in reducing the incidence of vertebral fractures. Secondary endpoints were percentage changes in baseline BMD at the lumbar spine and total hip at 1 and 2 years follow up. ResultsFull-text review of 144 articles yielded, 20 for meta-analysis. Bisphosphonates reduced the risk of vertebral fracture (pooled OR = 0.50, 95%CIs = 0.36–0.71) and significantly increased lumbar spine BMD after 1 year, by 4.42% vs placebo (95%CIs = 3.70%–5.14%). At the hip, this value was 2.94% (95%CIs = 2.13%–3.75%). Overall results of limited studies for non-bisphosphonate drugs showed increased BMD and raloxifene significantly decreases the risk of subsequent clinical vertebral fractures. ConclusionThe bisphosphonates are efficacious and most evident for the primary prevention of osteoporotic vertebral fractures, reducing their incidence and improving BMD in postmenopausal women with osteopenia or osteoporosis.
Highlights
Fragility fractures commonly cause disabilities and mortality in older adults and are major contributors to medical care costs worldwide (Sanchez-Riera and Wilson, 2017)
The U.S Preventive Services Task Force advises that all women aged more than 65 years should be screened for osteoporosis using dual-energy X-ray absorptiometry (DXA) (USPSTF et al, 2018), which reports results as T-scores based on the standard deviation of the mean bone mineral density (BMD) in the general population
The evidence gathered during this qualitative review indicate that the non-bisphosphonate agents denosumab, romosozumab, raloxifene, teriparatide, and calcitonin are eficacious in primary prevention, but meta-analysis was not possible with the small number of studies
Summary
Fragility fractures commonly cause disabilities and mortality in older adults and are major contributors to medical care costs worldwide (Sanchez-Riera and Wilson, 2017). A majority of such fractures occur in postmenopausal women without osteoporosis diagnoses (Lindsay et al, 2001), yet low bone mineral density (BMD) is recognized as an important preventable risk factor for osteoporotic fractures (Sanchez-Riera and Wilson, 2017). Women who develop osteoporotic vertebral and hip fractures are at substantial risk for additional fractures within 1 year (Johansson et al, 2017). The World Health Organization deines osteopenia (low bone mass) as a BMD T-score between −1 and − 2.5 at the hip or spine and osteoporosis as a T-score of −2.5 and below (World Health Organization, 2007). The intervention for subjects with low bone mass or osteoporosis but without clinical fracture is usually called as “primary” prevention of fracture
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