Persistence with Bisphosphonate Treatment for Osteoporosis: Finding the Root of the Problem

https://doi.org/10.1016/j.amjmed.2005.12.018Get rights and content

Abstract

Poor compliance and persistence are among the most significant reasons for failed pharmacotherapy encountered in clinical practice. Consequences of poor compliance range from minor to serious, depending on drug characteristics, disease state, and severity of disease. Compliance and persistence are particular problems for patients with a disorder such as osteoporosis, which remains asymptomatic for long periods. Poor compliance with bisphosphonate therapy for osteoporosis has been associated with a smaller decrease in the rate of bone turnover and smaller improvements in bone mineral density, and may potentially result in a higher risk of fracture and disability. The compliance problem is additive; complex dosing guidelines may contribute to poor compliance with therapy, and the failure to follow these guidelines may result in treatment-related adverse events that further reduce compliance. In the long term, these issues often result in nonpersistence with treatment. In addition to direct consequences for the patient, poor compliance is associated with significant healthcare costs. Studies suggest that less-frequent dosing regimens improve compliance; however, even among patients receiving weekly bisphosphonates, persistence may remain suboptimal. Several strategies are available to improve compliance and persistence with osteoporosis therapies. Good communication between the healthcare provider and the patient—with continuous reinforcement of the importance of treatment—is a key approach to improving persistence. Patients should receive feedback to confirm that their treatment is having an effect, and individualized reminder systems should be recommended to help the patient adhere to the treatment plan. Potentially, every patient is liable to discontinue treatment even after a long period of regular dosing. It should be assumed that every patient receiving therapy for osteoporosis needs regular reinforcement of the importance of continuing therapy.

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.

A

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

References (29)

  • J.A. Cramer

    Overview of methods to measure and enhance patient compliance

  • J.A. Cramer

    Partial medication compliancethe enigma of poor medical outcomes

    Am J Manag Care

    (1995)
  • B. Bender et al.

    Nonadherence in asthmatic patientsis there a solution to the problem?

    Ann Allergy Asthma Immunol

    (1997)
  • B.M. Psaty et al.

    The relative risk of incident coronary heart disease associated with recently stopping the use of beta-blockers

    JAMA

    (1990)
  • Cited by (0)

    View full text