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.

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💀

Cigarettes🚬

Chemo☢️

Alcohol🍺

Morphine💊

Antibiotics💉

Tylenol💊

Exercise🏃

Water💧

DangerousModerateSafe

Time to Effect

3-6 months

Duration

12 months (followed by anti-resorptive)

Response Rate

Remission Rate

Number Needed to Treat (NNT)

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

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)

Cyanide☠️

Meth💀

Cigarettes🚬

Chemo☢️

Alcohol🍺

Morphine💊

Antibiotics💉

Tylenol💊

Exercise🏃

Water💧

DangerousModerateSafe

Time to Effect

6-12 months

Duration

Long-term (often continued beyond 5 years)

Response Rate

Remission Rate

Number Needed to Treat (NNT)

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

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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Chemo☢️

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Morphine💊

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Tylenol💊

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Water💧

DangerousModerateSafe

Time to Effect

6-12 months

Duration

Up to 2 years lifetime maximum

Response Rate

Remission Rate

Number Needed to Treat (NNT)

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

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)

Cyanide☠️

Meth💀

Cigarettes🚬

Chemo☢️

Alcohol🍺

Morphine💊

Antibiotics💉

Tylenol💊

Exercise🏃

Water💧

DangerousModerateSafe

Time to Effect

6-12 months

Duration

3-6 years

Response Rate

Remission Rate

Number Needed to Treat (NNT)

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

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💀

Cigarettes🚬

Chemo☢️

Alcohol🍺

Morphine💊

Antibiotics💉

Tylenol💊

Exercise🏃

Water💧

DangerousModerateSafe

Time to Effect

6-12 months

Duration

3-5 years (re-evaluation after)

Response Rate

Remission Rate

Number Needed to Treat (NNT)

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

Raloxifene

45% Effectiveness• 80% Confidence• 60% Safety• 35 trials• 15K participants

HIGH EvidenceExcellent ValueDose: 60 mg orally once daily

Find Trials

Comparative Safety Scale(Higher is safer)

Cyanide☠️

Meth💀

Cigarettes🚬

Chemo☢️

Alcohol🍺

Morphine💊

Antibiotics💉

Tylenol💊

Exercise🏃

Water💧

DangerousModerateSafe

Time to Effect

6-12 months

Duration

Long-term

Response Rate

Remission Rate

Number Needed to Treat (NNT)

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