Comment on Freemantle et al.: Results of indirect and mixed treatment comparison of fracture efficacy for osteoporosis treatments.

Dear Editor, We were concerned by reading the meta-analysis of the fracture efficacy of osteoporosis treatments, published online in your journal on 26 July 2012 [1]. The conclusion of this analysis was that, while all osteoporosis treatments reduced vertebral fracture risk, and most decreased hip or nonvertebral fracture too, denosumab was more effective than alendronate, risedronate, raloxifene, and strontium ranelate, in preventing new vertebral fracture. While the authors used an appropriate methodology for the comparison of treatments via network meta-analysis, there appears to be a large heterogeneity in the studies included in the meta-analysis, raising some concern about its conclusions. First, of the 34 studies included, there was only one placebocontrolled trial of denosumab with fracture as primary endpoint (FREEDOM).