Persistence with Bisphosphonate Treatment for Osteoporosis: Finding the Root of the Problem
Section snippets
Consequences of inadequate compliance
The consequences of noncompliance may range from inconsequential to severe, depending on drug characteristics, disease state, and severity of disease. Approximately 10% of all hospitalizations and 23% of all nursing home admissions are attributable to a patient’s inability to follow drug therapy.2 For example, poor compliance with asthma medication regimens is associated with significantly more wheezing, greater variability in peak flow rates, lower asthma control scores, and a higher risk of
Compliance with osteoporosis medications
Poor compliance with osteoporosis medications has been shown to be associated with smaller decreases in the rate of bone turnover, lower gains in BMD, and a significantly greater risk of fracture. In addition, poor compliance with osteoporosis therapy increases both direct and indirect medical costs, and ultimately leads to decreased quality of life when fractures occur.12
Individuals who are compliant with bisphosphonate treatment have lower fracture rates. A study of 11,252 Canadian women who
Reasons for poor compliance with osteoporosis therapy
It is likely that failure to comply with osteoporosis therapy is a consequence of the lack of noticeable symptoms associated with the condition. Without obvious evidence of disease, patients may not believe their diagnosis, or they may accept the diagnosis but fail to perceive a sufficient threat to their health. Tolerability is another important factor to consider: studies suggest that upper gastrointestinal side effects are the major reason for discontinuation of bisphosphonate therapy.
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Improving compliance with osteoporosis therapy
Monitoring and feedback are particularly important in patients receiving treatment for a disease such as osteoporosis, which remains asymptomatic for long periods. Regular reinforcement of therapeutic progress demonstrates to patients that their osteoporosis therapy is having a beneficial effect. In a study conducted by Silverman and colleagues,24 140 women were randomized to receive educational information and a voucher for immediate BMD testing or educational information plus a voucher for
Role of physician–patient communication
Obstetricians/gynecologists and other primary care providers are ideally placed to ensure that patients initiate and persist with therapy. In addition to supplying frequent feedback on treatment progress, the clinician should continually reinforce the need for therapy. The Medication Usage Skills for Effectiveness (MUSE) program was developed as a simple behavioral intervention for clinicians to enhance medication compliance.26 This short, simple intervention takes 5 minutes to introduce and
Dosing regimen
Less-frequent dosing reduces disruption in patients’ lifestyles and may substantially enhance compliance and persistence with therapy. Weekly bisphosphonate regimens are preferred to daily regimens. In a 9-week crossover study, 86% of 266 women with postmenopausal osteoporosis preferred weekly over daily alendronate.27 The majority of patients perceived the weekly regimen as more convenient than the daily regimen and thought it would allow them to be more compliant with treatment (89% vs. 88%).
Summary
Poor compliance and persistence are among the most important reasons for failed pharmacotherapy in clinical practice, particularly in disease states that may remain asymptomatic for long periods, such as osteoporosis. Thus, compliance may be a particular problem in patients with osteoporosis, because it is considered a “silent” disease. Poor compliance with osteoporosis medications has been shown to be associated with smaller decreases in the rate of bone turnover, smaller gains in BMD, and a
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