In a study from the UK by Kanis et al. [122], generic alendronate was shown to be cost-effective in the prevention and treatment of fractures in postmenopausal women with a 10-year fracture probability for a major fracture that exceeded 7.5 % (Fig. 11). There was rather little difference in the threshold at different ages with a mean value of 7.0 %. Thus, the vast majority of treatment scenarios with alendronate can be considered as cost-effective (see Table 7). Fig. 11 Correlation between the 10-year probability of a major fracture (calculated with BMD) selleck products and cost-effectiveness of generic alendronate at the age of 50 years in women. Each point represents a particular combination of BMD and clinical risk factors (all

possible combinations of CRFs at BMD T-scores between 0 and −3.5 SD in 0.5 SD steps—512 combinations) with a BMI

set to 26 kg/m2. The horizontal line denotes the threshold for cost-effectiveness (a willingness to pay of £20,000/QALY gained) ([122], with permission from Elsevier) Other drugs that are approved for osteoporosis are click here associated with higher cost-effectiveness ratios compared to no treatment mainly due to their higher price. A recent study by Borgström et al. [287], again conducted in a UK setting, showed that risedronate was cost-effective above a 10-year probability of 13 % for a major osteoporotic G418 in vitro fracture. Other studies have examined strontium ranelate and denosumab in this way [288, 289]. However, the cost-effectiveness of different interventions will vary between countries due to differences PDK4 in drug costs, fracture risk, costs of treating fractures, utility estimates and willingness to pay. Despite differences in apparent cost-effectiveness, there is, however, no proven difference in efficacy between the majority of treatments [47, 290], and head-to-head comparisons of interventions with fracture outcomes are not available. For these reasons, the value of an incremental analysis between the individual treatments is questionable, since any resulting hierarchy of treatments is dependent largely on price, but otherwise meaningless in clinical terms. In addition, the large number of untreated patients makes

‘no treatment’ a relevant comparator. Notwithstanding, alendronate has been considered as a first-line intervention. The view arises, not because of apparent differences in efficacy between treatments, but because of cost. However, the poor effectiveness and side effect profile of many generic formulations challenge this view [197]. Acknowledgments We are grateful to the IOF Committee of Scientific Advisors and the ESCEO Scientific Advisory Board for their review of this paper and its endorsement. The paper updates the earlier guidance of ESCEO [2] ‘European guidance for the diagnosis and management of osteoporosis in postmenopausal women’, and some sections of text are reproduced with kind permission from Springer Science+Business Media B.V.