Osteoporotic fragility fractures constitute a significant public health concern. The lifetime risk of any
osteoporotic fracture is very high (40-50% in women and 13-22% in men). Fractures are associated with significant mortality and morbidity and represent a substantial economic burden to society.
Bisphosphonates (
alendronate,
etidronate,
risedronate and
ibandronate) are indicated for the treatment and prevention of
osteoporosis but are costly compared with other treatments, such as
vitamin D and
calcium. Our search identified 23 studies evaluating the cost effectiveness of
bisphosphonate therapy for the treatment and prevention of fragility fractures; these studies were from five geographical areas and employed a variety of comparators and assumptions. We identified 11 studies investigating
bisphosphonates in women with
low bone mineral density (BMD) [T-score >2.5 standard deviations {SDs} below normal {mean} peak values for young adults] and previous fractures, five studies investigating
bisphosphonates in women with low BMD and no previous fracture, one study of
bisphosphonates in women with
osteopenia, five studies involving screening and two studies of
bisphosphonates in special populations (women initiating
corticosteroid treatment and men). In women with low BMD and previous fractures,
bisphosphonate therapy was most cost effective in populations aged > or =70 years and was unlikely to be cost effective in populations aged < or =50 years. There was uncertainty concerning the cost effectiveness of
bisphosphonates in such populations aged 60-69 years. In women with low BMD without previous fractures, treatment with
alendronate or
risedronate appeared to be cost effective across countries (UK, US, Denmark), but there was some uncertainty about the cost effectiveness of
etidronate in patients in the highest age groups. Identifying risk factors for fractures through means such as spine radiographs to detect vertebral
deformities improves the cost effectiveness of treatment. In women with
osteopenia,
alendronate therapy may be cost effective in women with a T-score of -2.4SD in the US. Screening for low BMD and treatment with
alendronate or
etidronate appears to be cost effective in postmenopausal women in general and in women with
rheumatoid arthritis initiating
corticosteroid therapy.
Alendronate therapy without screening was also shown to be potentially cost effective in certain at-risk male populations, as well as in women initiating
corticosteroid therapy after the age of 40 years. Decision makers in the US, UK and Sweden should consider funding the use of
bisphosphonates for the prevention and treatment of
osteoporosis in women aged >70 years, particularly if they have other risk factors for fracture. Further studies are required to make more definitive conclusions in other countries and patient populations. Screening strategies for low BMD followed by
bisphosphonate treatment should also be considered in the general female population aged >65 years in the UK and US and in patients with
rheumatoid arthritis initiating
corticosteroid therapy.