Condition

Osteoporosis

Bone disease causing weakened, brittle bones

200M
People Affected
150
Active Trials
41.5M
New Cases/Year
460K
Deaths/Year

Treatment Rankings

Ranked by evidence volume first. Medicine has spent centuries ranking things by vibes. This is an improvement.

1
Romosozumab
75% Effectiveness• 85% Confidence• 55% Safety• 30 trials• 12K participants
HIGH EvidencePoor ValueDose: 210 mg subcutaneous injection once monthly
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Comparative Safety Scale(Higher is safer)

Cyanide☠️
Meth💀
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Morphine💊
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55
DangerousModerateSafe

Time to Effect

3-6 months

Duration

12 months (followed by anti-resorptive)

Response Rate

%

Remission Rate

%

Number Needed to Treat (NNT)

10

Number Needed to Harm (NNH)

200

Common Side Effects:

Arthralgia: 14%
Headache: 10%
Injection site reactions: 7%
Myocardial infarction: 0.8%
Stroke: 0.8%
Osteonecrosis of the jaw (ONJ): 0.05%
Atypical femoral fracture (AFF): 0.01%

Annual Cost of Care

Drug Cost

$27,000

Monitoring

$500

Side Effects

$200

Total Annual

$27,700

Cost-Effectiveness

POOR

QALYs Gained

0.3

ICER

$250,000/QALY

Treatment Outcomes
Primary Outcomes
Lumbar Spine Bone Mineral Density (BMD)0.850 g/cm^2
+13.5% (+0.115 g/cm^2)
Total Hip Bone Mineral Density (BMD)0.750 g/cm^2
+6.5% (+0.049 g/cm^2)
Femoral Neck Bone Mineral Density (BMD)0.650 g/cm^2
+5.3% (+0.034 g/cm^2)
New Vertebral Fracture Incidence (12 months)1.8% annual incidence
-73% (-1.3 percentage points annual incidence)
Secondary Benefits
P1NP (Procollagen Type 1 N-terminal Propeptide) (peak at Month 1)55 ng/mL
+145% (+80 ng/mL)
CTX (C-telopeptide of Type 1 Collagen) (nadir at Month 1)0.40 ng/mL
-25% (-0.10 ng/mL)
Clinical Fracture Incidence (12 months)4.0% annual incidence
-66% (-2.6 percentage points annual incidence)
Common Side Effects
Arthralgia
+14%
Headache
+10%
Injection site reactions
+7%

Clinical Trial Phases:

Phase 3Phase 4
2
Denosumab
70% Effectiveness• 90% Confidence• 60% Safety• 151 trials• 22K participants
HIGH EvidenceGood ValueDose: 60 mg subcutaneous injection every 6 months
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Comparative Safety Scale(Higher is safer)

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Meth💀
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60
DangerousModerateSafe

Time to Effect

6-12 months

Duration

Long-term (often continued beyond 5 years)

Response Rate

%

Remission Rate

%

Number Needed to Treat (NNT)

12

Number Needed to Harm (NNH)

500

Common Side Effects:

Back pain: 18%
Musculoskeletal pain: 15%
Hypercholesterolemia: 12%
Infection (e.g., cellulitis, UTI): 8%
Hypocalcemia: 3%
Osteonecrosis of the jaw (ONJ): 0.05%
Atypical femoral fracture (AFF): 0.01%
Rebound vertebral fractures upon discontinuation: 5%

Annual Cost of Care

Drug Cost

$2,250

Monitoring

$300

Side Effects

$150

Total Annual

$2,700

Cost-Effectiveness

GOOD

QALYs Gained

0.25

ICER

$75,000/QALY

Treatment Outcomes
Primary Outcomes
Lumbar Spine Bone Mineral Density0.850 g/cm²
+7.5% (+0.064 g/cm²)
Total Hip Bone Mineral Density0.750 g/cm²
+5.5% (+0.041 g/cm²)
Serum C-telopeptide (CTX)0.5 ng/mL
-70% (-0.35 ng/mL)
Annual Vertebral Fracture Rate2.5%
-68% (-1.7 percentage points)
Secondary Benefits
Forearm Bone Mineral Density0.600 g/cm²
+3% (+0.018 g/cm²)
Serum P1NP (Bone Formation Marker)50 ng/mL
-60% (-30 ng/mL)
Annual Non-vertebral Fracture Rate5.0%
-20% (-1.0 percentage points)
Common Side Effects
Back pain
+18%
Musculoskeletal pain
+15%
Hypercholesterolemia
+12%

Clinical Trial Phases:

Phase 3Phase 4
3
Teriparatide
70% Effectiveness• 85% Confidence• 55% Safety• 131 trials• 5.5K participants
HIGH EvidencePoor ValueDose: 20 mcg subcutaneous injection once daily
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Comparative Safety Scale(Higher is safer)

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Meth💀
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55
DangerousModerateSafe

Time to Effect

6-12 months

Duration

Up to 2 years lifetime maximum

Response Rate

%

Remission Rate

%

Number Needed to Treat (NNT)

11

Number Needed to Harm (NNH)

500

Common Side Effects:

Nausea: 9%
Leg cramps: 7%
Dizziness: 9%
Hypercalcemia: 7%
Hypotension: 2%

Annual Cost of Care

Drug Cost

$8,000

Monitoring

$400

Side Effects

$100

Total Annual

$8,500

Cost-Effectiveness

POOR

QALYs Gained

0.3

ICER

$200,000/QALY

Treatment Outcomes
Primary Outcomes
Risk of new vertebral fractures14.3% over 19 months (placebo incidence)
-65% (-9.3 percentage points over 19 months)
Lumbar Spine BMD0.75 g/cm² (average baseline T-score -2.5)
+10% (+0.075 g/cm²)
Femoral Neck BMD0.60 g/cm² (average baseline T-score -2.5)
+3% (+0.018 g/cm²)
P1NP (Bone Formation Marker)55 µg/L
+150% (+82.5 µg/L)
Secondary Benefits
Risk of new non-vertebral fractures5.6% over 19 months (placebo incidence)
-52% (-2.9 percentage points over 19 months)
Back Pain Severity (VAS)6/10 (VAS scale)
-25% (-1.5 points)
Annual Height Loss1.5 cm per year (in severe osteoporosis)
-50% (-0.75 cm per year)
Common Side Effects
Nausea
+9%
Leg cramps
+7%
Dizziness
+9%

Clinical Trial Phases:

Phase 3Phase 4
4
Zoledronic Acid
65% Effectiveness• 90% Confidence• 65% Safety• 112 trials• 20K participants
HIGH EvidenceExcellent ValueDose: 5 mg intravenous infusion once yearly
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Comparative Safety Scale(Higher is safer)

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65
DangerousModerateSafe

Time to Effect

6-12 months

Duration

3-6 years

Response Rate

%

Remission Rate

%

Number Needed to Treat (NNT)

15

Number Needed to Harm (NNH)

1000

Common Side Effects:

Acute phase reaction (fever, myalgia, arthralgia): 25%
Hypocalcemia: 3%
Renal impairment: 2%
Osteonecrosis of the jaw (ONJ): 0.05%
Atypical femoral fracture (AFF): 0.01%

Annual Cost of Care

Drug Cost

$250

Monitoring

$250

Side Effects

$50

Total Annual

$550

Cost-Effectiveness

EXCELLENT

QALYs Gained

0.18

ICER

$-3,000/QALY

Treatment Outcomes
Primary Outcomes
New Vertebral Fracture IncidencePlacebo rate: 10.7% over 3 years
-70% (-7.5% (absolute reduction in incidence))
New Hip Fracture IncidencePlacebo rate: 2.5% over 3 years
-41% (-1.0% (absolute reduction in incidence))
Lumbar Spine Bone Mineral Density (BMD)0.850 g/cm²
+6.7% (+0.057 g/cm²)
Femoral Neck Bone Mineral Density (BMD)0.600 g/cm²
+5.1% (+0.031 g/cm²)
Secondary Benefits
New Non-Vertebral Fracture IncidencePlacebo rate: 12.2% over 3 years
-25% (-3.0% (absolute reduction in incidence))
Total Hip Bone Mineral Density (BMD)0.700 g/cm²
+5% (+0.035 g/cm²)
Serum C-Telopeptide (CTX) - Bone Resorption Marker0.5 ng/mL
-70% (-0.35 ng/mL)
Common Side Effects
Acute phase reaction (fever, myalgia, arthralgia)
+25%
Hypocalcemia
+3%
Renal impairment
+2%

Clinical Trial Phases:

Phase 3Phase 4
5
Alendronate
60% Effectiveness• 90% Confidence• 65% Safety• 154 trials• 100K participants
HIGH EvidenceExcellent ValueDose: 70 mg orally once weekly or 10 mg orally once daily
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Comparative Safety Scale(Higher is safer)

Cyanide☠️
Meth💀
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65
DangerousModerateSafe

Time to Effect

6-12 months

Duration

3-5 years (re-evaluation after)

Response Rate

%

Remission Rate

%

Number Needed to Treat (NNT)

15

Number Needed to Harm (NNH)

1000

Common Side Effects:

Esophageal irritation/ulcer: 5%
Abdominal pain: 8%
Musculoskeletal pain: 7%
Nausea: 3%
Diarrhea: 2%
Osteonecrosis of the jaw (ONJ): 0.005%
Atypical femoral fracture (AFF): 0.005%

Annual Cost of Care

Drug Cost

$75

Monitoring

$250

Side Effects

$50

Total Annual

$375

Cost-Effectiveness

EXCELLENT

QALYs Gained

0.15

ICER

$-5,000/QALY

Treatment Outcomes
Primary Outcomes
Lumbar Spine Bone Mineral Density (BMD)0.750 g/cm² (equivalent to T-score approx. -2.5)
+7% (+0.053 g/cm²)
Total Hip Bone Mineral Density (BMD)0.680 g/cm² (equivalent to T-score approx. -2.0)
+4% (+0.027 g/cm²)
Reduction in Incident Vertebral Fractures (Relative Risk)Cumulative incidence of vertebral fractures over 3 years: 15% in placebo group
-48% (-7.2% (absolute reduction in cumulative incidence))
Reduction in Incident Hip Fractures (Relative Risk)Cumulative incidence of hip fractures over 3 years: 2.8% in placebo group
-45% (-1.26% (absolute reduction in cumulative incidence))
Secondary Benefits
Serum C-telopeptide (CTX)0.600 ng/mL (upper normal range for postmenopausal women)
-55% (-0.330 ng/mL)
Back Pain Severity (VAS Score)6.0/10 (Visual Analog Scale)
-25% (-1.5 points)
Quality of Life (EQ-5D Index Score)0.68 (EQ-5D Index, range 0-1)
+8% (+0.0544 points)
Common Side Effects
Esophageal irritation/ulcer
+5%
Abdominal pain
+8%
Musculoskeletal pain
+7%

Clinical Trial Phases:

Phase 3Phase 4
6
Raloxifene
45% Effectiveness• 80% Confidence• 60% Safety• 35 trials• 15K participants
HIGH EvidenceExcellent ValueDose: 60 mg orally once daily
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Comparative Safety Scale(Higher is safer)

Cyanide☠️
Meth💀
Cigarettes🚬
Chemo☢️
Alcohol🍺
Morphine💊
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60
DangerousModerateSafe

Time to Effect

6-12 months

Duration

Long-term

Response Rate

%

Remission Rate

%

Number Needed to Treat (NNT)

20

Number Needed to Harm (NNH)

150

Common Side Effects:

Hot flashes: 20%
Leg cramps: 8%
Peripheral edema: 7%
Venous thromboembolism (DVT, PE): 2%

Annual Cost of Care

Drug Cost

$150

Monitoring

$250

Side Effects

$50

Total Annual

$450

Cost-Effectiveness

EXCELLENT

QALYs Gained

0.08

ICER

$20,000/QALY

Treatment Outcomes
Primary Outcomes
Incidence of New Vertebral Fractures14% over 3 years (placebo-controlled trials)
-40% (-5.6% (from 14% to 8.4%))
Lumbar Spine Bone Mineral Density (BMD)0.850 g/cm² (T-score -2.8)
+2.5% (+0.021 g/cm²)
Femoral Neck Bone Mineral Density (BMD)0.750 g/cm² (T-score -2.5)
+2% (+0.015 g/cm²)
Serum C-telopeptide (CTX)0.5 ng/mL
-25% (-0.125 ng/mL)
Secondary Benefits
LDL Cholesterol140 mg/dL
-12% (-16.8 mg/dL)
Total Cholesterol220 mg/dL
-7% (-15.4 mg/dL)
Incidence of Invasive Breast Cancer1.5% over 8 years (placebo in high-risk women)
-60% (-0.9% (from 1.5% to 0.6%))
Common Side Effects
Hot flashes
+20%
Leg cramps
+8%
Peripheral edema
+7%

Clinical Trial Phases:

Phase 3Phase 4