Impact of anti-osteoporosis medication on refracture prevention following osteoporotic vertebral fracture: a systematic review and meta-analysis

Osteoporotic vertebral fractures (OVFs) increase mortality and impair patients’ quality of life. Previous studies have focused on the effects of anti-osteoporosis drugs for primary fracture prevention; however, their role in secondary prevention remains insufficiently explored. Since refractures lead to more serious health issues and are strongly associated with prior fractures and low bone mineral density (BMD), effective treatment strategies for patients with existing OVFs are crucial. A systematic search was conducted using PubMED, Cochrane Library, and EMBASE according to PRISMA guidelines. Two reviewers independently selected and assessed relevant studies. A meta-analysis was conducted to examine the effects of anti-osteoporosis medications on refracture prevention in adult patients with existing OVFs. A total of 33 studies were included in the analysis. Compared to the control, bisphosphonates were associated with lower subsequent vertebral fracture (VF) rates at 1 year [OR = 0.29, 95% CI = 0.20–0.43], 3 years [OR = 0.51, 95% CI = 0.42–0.62], and final follow-up [OR = 0.35, 95% CI = 0.26–0.48]; greater BMD percent changes at 1 year [MD = 3.65, 95% CI = 2.63–4.67], 2 years [MD = 5.39, 95% CI = 3.87–6.92], and 3 years [MD = 5.44, 95% CI = 4.38–6.51]; improved VAS scores at 6 months [MD (95% CI) = -0.41 (-0.67, -0.14)] and 12 months [MD (95% CI) = -0.92 (-1.25, -0.59)]; and improved ODI scores at 12 months [SMD (95% CI) = -1.89 (-3.07, -0.71)]. Teriparatide was associated with lower subsequent VF rates compared to the control [OR = 0.39, 95% CI = 0.16–0.97] and bisphosphonates [OR = 0.41, 95% CI = 0.30–0.56], and led to improved VAS scores at 3 months [MD (95% CI) = -1.41 (-2.47, -0.35)] compared to bisphosphonates. Vitamin D improved RMDQ scores at 3 months [MD (95% CI) = -1.59 (-2.88, -0.31)] compared to the control. Additionally, romosozumab was associated with lower subsequent VF rates compared to bisphosphonates in patients undergoing vertebral augmentation [OR = 0.21, 95% CI = 0.09–0.51]. Teriparatide may be considered a preferred option for secondary fracture prevention in patients with OVFs. Romosozumab demonstrated potential benefit in patients after vertebral augmentation, although the supporting evidence is limited. Bisphosphonates may remain a reasonable alternative when anabolic agents are unavailable or contraindicated.