Comparative efficacy and safety of pharmacological interventions for postmenopausal osteoporosis: a network meta-analysis

Characterized as a common chronic metabolic bone disease, postmenopausal osteoporosis (PMOP) leads to fractures, functional impairment, and a higher risk of death in middle-aged and elderly women. Although various pharmacological interventions are available, their comparative efficacy and safety profiles remain uncertain. A comprehensive systematic search was performed across multiple electronic databases, including PubMed, Embase, the Cochrane Library, and Web of Science from August 1995 to March 2026. We included published randomized controlled trials (RCTs). Outcomes included lumbar spine bone mineral density (LS-BMD), femoral neck BMD(FN-BMD), total hip BMD(TH-BMD), trochanter BMD(TRO-BMD), etc. The analysis included 41 studies with 3,9429 patients and 7 drug classes. Based on SUCRA rankings, calcitonin_minodronate achieved the highest rank for both LS-BMD (SUCRA = 91%) and FN-BMD (SUCRA = 87.7%). For TH-BMD, abaloparatide (SUCRA = 89.8%) ranked highest, while alendronate (SUCRA = 94.3%) occupied the top position for TRO-BMD. Regarding bone turnover markers, ibandronate (SUCRA = 9.6%) showed the highest rank for C-terminal telopeptide of type I collagen (CTX), whereas teriparatide (SUCRA = 99.4%) ranked highest for N-propeptide of type I collagen(P1NP). In terms of safety outcomes, calcitonin(SUCRA = 9.1%) ranked lowest for serious adverse events. For fracture outcomes, abaloparatide ranked lowest for vertebral (SUCRA = 6.1%) and non-vertebral fractures (SUCRA = 12.8%), The magnitude of treatment effects is presented in the full league tables. Each drug class offered distinct advantages in PMOP treatment. Therapy should be individualized based on efficacy and safety profiles. This study supported personalized management strategies for postmenopausal osteoporosis. Registration of systematic reviews : CRD420251149474, PROSPERO.