- Design
- Cochrane systematic review and meta-analysis of randomised trials, GRADE
- Population
- 4,132 men aged 50 or older in 17 trials
- Primary outcome
- Hip, symptomatic vertebral and other fractures; adverse events
- Effect
- Bisphosphonates vs placebo: hip RR 0.73 (0.06-8.51); vertebral RR 0.49 (0.14-1.74); very low certainty
This Cochrane review included 17 randomised trials of 4,132 men aged 50 or older comparing bisphosphonates, PTH or PTHrP analogues, denosumab or romosozumab with placebo or other treatments, with GRADE assessment.
Against placebo, bisphosphonates gave hip fracture RR 0.73 (95% CI 0.06-8.51), symptomatic vertebral fracture RR 0.49 (0.14-1.74) and other fracture RR 0.78 (0.42-1.45), all very low certainty, over up to two years. Bisphosphonates probably did not increase adverse events (RR 1.06) or serious adverse events (RR 0.95), moderate certainty. Evidence for the other drugs was similarly very uncertain.
Most osteoporosis trials enrolled women, and treatment in men rests largely on bone density changes and extrapolation. This review shows the fracture data in men are too few events to confirm or exclude benefit, not that the drugs do not work.
In practice, men with a fragility fracture or high fracture risk still merit treatment, and bisphosphonates look safe; the uncertainty belongs in the shared decision.
- Continue to assess and treat men after fragility fractures; under-treatment in men is common.
- Explain that fracture evidence in men is borrowed largely from women and from bone density data.
- Bisphosphonates remain a reasonable, safe first choice.
- Look for secondary causes in men: hypogonadism, glucocorticoids, alcohol, androgen deprivation therapy.
Why it matters
It exposes that fracture prevention in men rests on extrapolation, which matters when men are already the group least often treated.
Don't overread it
Very uncertain means too few fractures to tell, not proof that the drugs fail to prevent fractures in men.
The statistics, in plain English
The hip fracture confidence interval, from 0.06 to 8.51, spans a 94% reduction to an eightfold increase, because there were only four hip fractures in total. Intervals that wide carry almost no information in either direction.
Read the rest in the app
You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.
Scan to keep reading on your phone. No account needed to start.
Tomorrow morning, before your first patient
One edition a day for orthopaedics, written by the desk, every claim tied to its paper. Six minutes.
Get the app — free