• Romosozumab significantly increases lumbar spine, total hip, and femoral neck bone mineral density at 6 and 12 months compared with placebo, alendronate, and teriparatide.
• Compared with denosumab, romosozumab provides superior lumbar spine BMD gains but similar hip and femoral neck BMD changes.
• Romosozumab has a lower adverse event rate than alendronate but higher than teriparatide; no significant differences versus placebo or denosumab.
• Romosozumab does not significantly increase cardiovascular complication risk, supporting its use in high-fracture-risk patients without cardiovascular contraindications.