Meta-analysis of clinical fracture risk reduction of anti-osteoporosis drugs: direct and indirect comparisons and meta-regressions

Evaluating SARC-F, SARC-CalF, and calf circumference as diagnostic tools for sarcopenia in Thai older adults: results from a nationwide study

BACKGROUND

With the increasing number of older adults, musculoskeletal disorders such as sarcopenia have become increasingly important to research because of their strong association with falls and fractures. Sarcopenia, which is characterized by reduced muscle mass, is common among older adults and significantly increases the risk of falls. This study aimed to assess the effectiveness of the SARC-F and SARC-CalF questionnaires, along with calf circumference measurements, for sarcopenia screening among Thai community-dwelling older adults, following the 2019 criteria of the Asian Working Group for Sarcopenia.

METHODS

This analysis drew on data from the Thai Musculoskeletal Diseases Nationwide Study, which included 2543 participants aged 60 years or older. The SARC-F, SARC-CalF, and calf circumference data were evaluated against the 2019 Asian Working Group for Sarcopenia criteria. We calculated the sensitivity, specificity, and area under the curve to determine the diagnostic performance of each tool.

RESULTS

Of the 2455 participants analyzed, 18.1% were diagnosed with sarcopenia. The SARC-F and SARC-CalF questionnaires showed limited effectiveness in diagnosing sarcopenia, with area under the curve values of 0.508 and 0.729, respectively. In contrast, calf circumference demonstrated greater diagnostic accuracy, with area under the curve values of 0.897 in males and 0.878 in females. Adjusting the cutoff points to < 33 cm for males and < 31 cm for females improved the overall diagnostic accuracy from 66.4 to 82%.

CONCLUSIONS

Sarcopenia is relatively prevalent in Thailand. The SARC-F and SARC-CalF questionnaires are inadequate for diagnosing sarcopenia, while calf circumference alone is the most effective screening tool. Adding more parameters to the SARC-F questionnaire could enhance its diagnostic accuracy.

TRIAL REGISTRATION

This study was registered at ClinicalTrials.gov (NCT06558617). Registration Date 16 August 2024.

Comparison of anti-fracture effectiveness of zoledronate, ibandronate and alendronate versus denosumab in a registry-based cohort study

This registry-based study of 3068 patients with osteoporosis compared the anti-fracture effectiveness of denosumab versus bisphosphonates. Denosumab was associated with significantly greater risk reduction than alendronate or ibandronate for vertebral and any fractures. No difference in fracture risk reduction was found between zoledronate and denosumab.

PURPOSE

To analyse the fracture risk of patients with osteoporosis receiving bisphosphonates or denosumab in a real-world setting.

METHODS

This registry-based cohort study evaluated patients taking denosumab, bisphosphonates or both sequentially. Fractures were analysed using rates, rate ratios and hazard ratios (HR), including both therapies as time-varying co-variates. Fracture risk hazards were adjusted (aHR) for baseline T-Scores and trabecular bone score (TBS) and were additionally analysed with inverse probability treatment weighting.

RESULTS

A total of 3068 patients (89% female; median age at treatment onset, 69 years [63 to 76]) received denosumab (median duration 2.8 years, [2.2 to 4.7]), bisphosphonates (3.4 years, [2.1 to 5.7]) or both sequentially. Thus, 11,078 subject-years were assessed for bisphosphonates (41% alendronate, 36% ibandronate, 23% zoledronate) and 4216 for denosumab. Moreover, 48,375 subject-years were observed before treatment onset, in addition to 2593 years of drug holidays. A total of 1481 vertebral fractures (435 under therapy), 1508 non-vertebral fractures (499 under therapy) and 202 hip fractures (67 under therapy) occurred after age 50. The risks of vertebral, non-vertebral and hip fractures were significantly lower under all bisphosphonates, denosumab and drug holidays than before treatment onset (all p < 0.001). After adjusting for age, baseline T-scores and TBS, denosumab was associated with lower risk than alendronate or ibandronate for vertebral fractures (aHR 0.47 (0.35 to 0.64) and 0.70 [0.53 to 0.91], p < 0.001 and p = 0.009, respectively) and any fractures (aHR 0.62 [0.51 to 0.76] and 0.77 [0.64 to 0.92], p < 0.001 and p = 0.004). With propensity weighting, denosumab was associated with a lower hip fracture risk compared to alendronate (HR 0.54 [0.29 to 0.98], p = 0.044). No difference in fracture risk reduction (vertebral, non-vertebral or hip) was found between zoledronate and denosumab.

CONCLUSIONS

When adjusting for disease severity, denosumab was associated with significantly greater risk reduction than alendronate and ibandronate for vertebral fractures. No difference in fracture risk reduction was found between zoledronate and denosumab.

Real-life short-term effectiveness of anti-osteoporotic treatments: a longitudinal cohort study

Introduction:

Randomized clinical trials have shown that anti-osteoporotic treatments can increase bone mineral density (BMD) and reduce the incidence of fragility fractures. However, data on the real-life effectiveness of anti-osteoporotic medications are still scarce.

Methods:

We conducted a cohort study on women at high risk of fracture. We retrieved clinical and densitometric data from the DeFRA database, which derives from the DeFRA tool, a web-based fracture risk assessment tool. Multivariable Cox regression survival models were employed to analyze the effectiveness of different anti-osteoporotic drugs on fracture. In sensitivity analyses, we conducted 1:1 propensity score matching analyses.

Results:

Data on 50,862 women were available. Among these, 3574 individuals had at least two consecutive visits. The crude fracture rate was 91.9/1000 person-year for non-treated patients. The crude fracture rate in bisphosphonate users was 72.1/1000 person-year, in denosumab users was 58.2/1000 person-year, and in teriparatide users was 19.3/1000 person-year. Overall, we found that bisphosphonate use was associated with a 30% lower risk of fracture compared to no treatment [adjusted hazard ratio (aHR): 0.70, 95% confidence interval (CI): 0.50–0.98]. Treatment with denosumab and teriparatide were associated with 60% and 90% lower risk of fracture, respectively (aHR: 0.43, 95% CI: 0.24–0.75 and aHR: 0.09, 95% CI: 0.01–0.70). Bisphosphonate use was associated with a lower risk of fracture only after 1 year of treatment.

Conclusion:

In conclusion, we found that all anti-osteoporotic medications considered in the study effectively reduced the risk of fracture in the real-life. The effect of bisphosphonate on fracture risk was apparent only after the first year of treatment. Our findings do not support the use of bisphosphonates in patients at imminent risk of fracture.