OBJECTIVES: To evaluate the relative health gains and costs of secondary prevention of fractures with generic alendronate, risedronate, denosumab and zoledronic acid. METHODS: We evaluated the cost-effectiveness based on a previously developed decision analytic fracture model. The model synthesizes available data on the epidemiology of fractures and related mortality, need for long-term care and home based assistance. The model is set up as an individual level Markov model and outputs include number of quality adjusted life years (QALYs) and costs. Effectiveness data were gathered from a recent systematic review and costs were collected from publicly available sources.  We preformed analyses for women 85 years old with a previous hip fracture. In this first preliminary analysis, we assumed full compliance and lifelong treatment. RESULTS: Zoledronic acid was the most effective alternative, followed by denosumab, risedronate, generic alendronate and no treatment, yielding respectively 4.7661, 4.7640, 4.6715, 4.1581 and 3.8915 QALYs.  In terms of costs, generic alendronate was the best options, being less costly than no secondary prevention. In terms of cost-effectiveness, no treatment, denosumab and risedronate were excluded based on dominance, seeing that alendronate was more effective and less costly than no treatment, and zoledronic acid was more effective and less costly than both denosumab and risedronate. Compared to alendronate, zoledronic acid yields an incremental cost-effectiveness ratio of $48,832 per QALY. CONCLUSIONS: All options are effective compared to no treatment. In terms of comparative effectiveness and cost-effectiveness, our analysis indicates that zoledronic acid is the optimal strategy for secondary prevention, assuming a cost-effectiveness threshold of $50,000 per QALY gained.