What are the cost-effective injectable osteoporosis medications?

Cost-Effective Injectable Osteoporosis Medications

Zoledronic acid (intravenous bisphosphonate) is the most cost-effective injectable medication for osteoporosis, with an estimated cost of $58 per year for annual dosing or $92.79 for biannual dosing. 1

Injectable Options Ranked by Cost

First-Line Injectable Option

• Zoledronic acid (intravenous bisphosphonate) is significantly less expensive than other injectable options, costing approximately $58 for yearly administration or $92.79 for twice-yearly administration 1
• Generic zoledronate has been identified in systematic reviews as one of the most cost-effective initial therapies for postmenopausal osteoporosis 1
• The maximum benefit from bisphosphonates, including zoledronic acid, is observed in patients with high baseline risk for fractures 1

Second-Line Injectable Option

• Denosumab (subcutaneous injection) costs approximately $2,292.48 annually ($1,146.24 per dose given every 6 months) 1
• Despite higher costs, denosumab may be cost-effective compared to other osteoporotic treatments in specific populations:
  • Older adults (particularly those over 75 years) 2
  • Patients with previous fractures 2
  • Those with lower bone mineral density T-scores 2
  • Men with osteoporosis (ICER of $16,888 compared to generic alendronate) 3

Clinical Considerations for Injectable Options

Zoledronic Acid Benefits

• Consistently ranks among the top two treatments for improving bone mineral density at all skeletal sites 1
• Can be administered yearly or every two years, reducing the frequency of medical visits 1
• Particularly beneficial for patients with adherence issues to oral medications 1

Denosumab Benefits

• Improves patient adherence and persistence compared to oral bisphosphonates 2
• Reduces vertebral fracture risk (RR, 0.15; P = .004 at 12 months) 1
• Shown to be more effective than alendronate in decreasing bone turnover markers and increasing BMD 1

Important Caveats and Pitfalls

• The overall treatment cost for injectable formulations may be higher than the medication cost alone due to:
  • Clinic visit reimbursements 1
  • Infusion costs (for intravenous medications) 1
  • Potential missed work hours for working patients 1
• Discontinuation of denosumab should be followed by an alternative sequential treatment to prevent rebound fractures 1, 4
• Dental evaluation is recommended before initiating denosumab therapy to reduce risk of osteonecrosis of the jaw 4
• Vitamin D deficiency should be corrected with adequate calcium intake throughout denosumab treatment 4

Special Populations

Cancer Patients

• For patients receiving aromatase inhibitors or androgen deprivation therapy, denosumab (60mg every 6 months) is recommended if T-score is <-2.0 or if patient has ≥2 clinical risk factors for fracture 4
• In cancer treatment-induced bone loss, denosumab reduced fracture risk by 50% compared to placebo 4

Men with Osteoporosis

• Oral bisphosphonates have been proven cost-effective in men 55 years of age or older with a history of fracture, low bone mass, rheumatoid arthritis, or use of high-dose glucocorticoids 1
• Denosumab has been shown to be cost-effective compared with bisphosphonates and teriparatide in high-risk male populations 1, 3

Algorithm for Selecting Injectable Osteoporosis Treatment

1. For most patients requiring injectable therapy, start with zoledronic acid (yearly or every 6 months) due to lowest cost 1
2. Consider denosumab if:
   • Patient has very high fracture risk 2
   • Patient is over 75 years of age 2
   • Patient has history of previous fractures 2
   • Patient is receiving cancer treatments like ADT or aromatase inhibitors 4
3. Consider teriparatide only for patients with very high risk of fracture (recent vertebral fractures, hip fracture with T score ≤-2.5) followed by an antiresorptive agent 5