A Bayesian analysis of bisphosphonate effects and cost-effectiveness in post-menopausal osteoporosis

Objective - Effects of oral bisphosphonates on the rate of vertebral fractures in post-menopausal osteoporotic women have been found in clinical trials. We wanted to compare the effects of two bisphosphonates, alendronate and etidronate, and calculate the price difference that would give the same cost-effectiveness for the two drugs. We also intended to give, by means of Bayesian statistics, probability distributions and point and interval estimates for key parameters. Methods - We used published, double-blind, randomized placebo controlled studies describing the results of occurrence of vertebral fractures at 3-year follow-up in post-menopausal women taking bisphosphonates. Four studies were identified, including altogether 3510 women. The women had either suffered a fracture at entry or had a bone density at least 2.5 SD below the mean value for young women. Two of the studies dealt with alendronate and two with etidronate. Results - According to three of the studies, the number of women out of 100 avoiding vertebral fractures during a 3-year observation period varied from two to seven. The fourth study did not contain the necessary data. The four studies showed that, for the incidence rate, the multiplicative treatment effects were respectively 0.45, 0.74, 0.40 and 0.36, where values less than 1 indicate positive treatment effects. Using data from all four studies, a comparison of the two drugs gave a point estimate of 0.247 with 95% credibility interval (CI): -0.051 to 0.496 for a difference in effect in favour of alendronate measured in terms of risk ratio of fracture and 0.302 (CI: 0.099 to 0.539) measured as incidence rate ratio. Based on two studies, showing about the same prevalence of fractures in the control groups, the difference in the risk difference between the two drugs was 0.028 (CI: -0.039 to 0.079). Conclusions - Bisphosphonates effectively reduce risk of new vertebral fractures, but alendronate is somewhat more effective than etidronate. To obtain equal cost-effectiveness alendronate should be priced 40-70% higher than etidronate. Copyright (C) 2000 John Wiley & Sons, Ltd.