# A comprehensive update on the cost-effectiveness of 10-year denosumab vs alendronate in postmenopausal women with osteoporosis in the United States

## TL;DR

This study finds that 10 years of denosumab treatment is cost-effective compared to a 5-year alendronate regimen with a drug holiday for postmenopausal women with osteoporosis in the US.

## Contribution

The study updates a previous analysis by evaluating the cost-effectiveness of a 10-year denosumab treatment duration.

## Key findings

- Denosumab had an incremental cost-effectiveness ratio of $97,574 per QALY gained compared to alendronate.
- Denosumab was considered cost-effective in 62.1% of simulations at a $150,000 per QALY threshold.
- Denosumab was dominant over no treatment in the analysis.

## Abstract

In postmenopausal women with osteoporosis, 10-year denosumab was estimated to be cost-effective vs 5 years of oral alendronate, a 2-year drug holiday, and subsequently 3-years of alendronate with an estimated incremental cost-effectiveness ratio of $97,574 per quality-adjusted life-years gained. Cost-effectiveness was demonstrated in most of the scenario simulations.

A previous economic analysis estimated that 5-year denosumab was cost-effective compared with 5-year alendronate in women with postmenopausal osteoporosis (PMO) in the United States (US). Emerging literature has provided data on the long-term clinical benefits of denosumab. Therefore, the cost-effectiveness analysis was updated to understand the potential implications of a longer treatment duration (10-year) with denosumab vs generic oral alendronate or no treatment from a US third-party payer perspective.

A lifetime Markov cohort model was used to compare 10-year denosumab treatment to 5 years of alendronate, followed by a 2-year drug holiday and, then an additional 3 years of alendronate. The target population consisted of PMO women in the US with a starting age of 72 years. Recent publicly available data, including epidemiology, treatment efficacy, persistence, and costs, were used to inform model inputs. Scenario analyses and a probabilistic sensitivity analysis (PSA) were conducted to account for uncertainty.

Estimated mean total lifetime cost and quality-adjusted life years (QALYs), respectively, were $81,003 and 8.035 for denosumab, and $75,358 and 7.977 for alendronate, resulting in denosumab having an incremental cost-effectiveness ratio of $97,574 per QALY gained. At a threshold of $150,000 per QALY, the PSA demonstrated that denosumab was considered cost effective in 62.1% of simulations. Denosumab was dominant over no treatment.

Ten-year denosumab treatment would be cost-effective compared with 5 years of alendronate, followed by a 2-year drug holiday and 3 years of alendronate at the threshold of $150,000. Cost-effectiveness was demonstrated across most scenarios with robust PSA results.

The online version contains supplementary material available at 10.1007/s11657-025-01564-x.