Original Article

Osteoporosis International

, Volume 21, Issue 4, pp 679-688

Bisphosphonates and osteoporotic fractures: a cross-design synthesis of results among compliant/persistent postmenopausal women in clinical practice versus randomized controlled trials

  • M. M. WilkesAffiliated withHygeia Associates Email author 
  • , R. J. NavickisAffiliated withHygeia Associates
  • , W. W. ChanAffiliated withEvidence Based Medicine, Novartis Pharmaceuticals Corp
  • , E. M. LewieckiAffiliated withNew Mexico Clinical Research & Osteoporosis Center

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In a cross-design synthesis, total fractures were similarly reduced by bisphosphonates among postmenopausal women in randomized trials (23.8%) and highly compliant/persistent patients in observational studies of large databases from routine practice (20.3%). Bisphosphonates also reduced nonvertebral, vertebral and hip fractures in randomized trials and observational studies. In the real-word setting, compliant/persistent patients can gain a benefit from bisphosphonates comparable to that of randomized trial participants.


The purpose of the study was to determine whether clinical fracture risk reduction by bisphosphonate treatment in women with postmenopausal osteoporosis differs between randomized controlled trials and routine practice.


Randomized trials comparing bisphosphonate with placebo and observational studies comparing highly compliant/persistent with less compliant/persistent patients were sought by electronic searches and ancillary methods. Clinical fracture data were extracted from the study reports and quantitatively combined by random effects metaanalysis.


The odds ratio (OR) for all clinical fractures in randomized trials of 0.762, with a 95% confidence interval (CI) of 0.680–0.855, was closely similar to that in the observational studies (OR, 0.797; CI, 0.748–0.850). Pooled clinical fracture reduction across both study designs was 22%. Nonvertebral, vertebral, and hip fractures were also significantly reduced by bisphosphonate treatment in both randomized trials and observational studies.


Compliant/persistent patients in the “real-world” setting benefit from bisphosphonate treatment to a similar extent as patients in randomized trials.


Bisphosphonates Compliance Fractures Osteoporosis Persistence