Efficacy and Safety of Bisphosphonates for Complex Regional Pain Syndrome : A Systematic Review and Meta-analysis.

Abstract

Clinical guidelines recommend bisphosphonates for complex regional pain syndrome (CRPS) despite limited evidence of efficacy. To determine the efficacy and safety of bisphosphonates compared with placebo for CRPS. MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and 3 trial registries from inception to 16 September 2025. Randomized controlled trials enrolling adults with CRPS (type I or II) to bisphosphonate treatment or placebo. Primary outcomes were pain intensity and adverse events. Data were synthesized with random-effects meta-analyses. Risk of bias and certainty of evidence were assessed using the Cochrane Risk of Bias 2 Tool and GRADE (Grading of Recommendations Assessment, Development and Evaluation). Eleven trials (754 participants; CRPS type I, 97%), evaluating alendronate (<i>n</i> = 2), clodronate (<i>n</i> = 1), neridronate (<i>n</i> = 5), pamidronate (<i>n</i> = 1), and zoledronate (<i>n</i> = 2), were included. Bisphosphonates may result in little to no difference in pain intensity in the immediate term (≤4 weeks; 0-to-100 scale; mean difference [MD], -9.1 [95% CI, -19.2 to 1.1]; low certainty). In the short term (>4 weeks to 3 months; primary time point), bisphosphonates may reduce pain intensity (MD, -10.0 [CI, -18.9 to -1.1]; low certainty), and in the medium term (>3 to 6 months), they may result in little to no difference in pain intensity (MD, 8.0 [CI, -15.4 to 31.4]; low certainty). The evidence is very uncertain about the effects of bisphosphonates on pain intensity in the long term (>6 months; MD, -2.5 [CI, -19.6 to 14.6]). Bisphosphonates probably increase risk for adverse events (risk ratio, 1.1 [CI, 1.0 to 1.2]; moderate certainty). High heterogeneity and uncertain medium- and long-term effects. Evidence mostly applies to CRPS type I and includes non-U.S.-approved formulations (neridronate, clodronate). Bisphosphonates may reduce CRPS pain intensity in the short term, but treatment is accompanied by adverse events. Future research should resolve uncertainty around which patients with CRPS are most likely to benefit from bisphosphonates. None. (PROSPERO: CRD42024559783).