Compliance with drug therapies for the treatment and prevention of osteoporosis

Alendronate adherence and its impact on hip-fracture risk in patients with established osteoporosis in Taiwan

A pharmacoepidemiology study was conducted using the health insurance database in Taiwan to assess compliance with osteoporosis drug regimens and the impact of compliance on the risk for secondary fractures. Patients >50 years of age with vertebral/hip fracture who had been started on alendronate therapy for the first time only after the fracture were included. Compliance was measured using the medication possession ratio (MPR) and was included as a time-dependent covariate in the Cox model to compare the difference between compliant (MPR ≥ 80%) and noncompliant patients (MPR <80%) with respect to risk for subsequent hip fractures. Only 38% of the study population remained compliant during the first year of treatment. Over the 4-year follow-up period, the risk of hip fracture among the compliant patients was 70% lower than that among the noncompliant ones (adjusted hazard ratio (HR) 0.30). Among patients with osteoporosis in Taiwan who had experienced a fracture and had started alendronate therapy, compliance with the dosage regimen was suboptimal. It was also found that compliance significantly reduced the risk of secondary hip fracture up to 4 years.

Role of zoledronic acid in the prevention and treatment of osteoporosis

Taken once a year, intravenous zoledronic acid (Zol) (Reclast® or Aclasta®) is a third-generation nitrogen-containing bisphosphonate that is effective compared with placebo in reducing the risk of fractures in patients with postmenopausal osteoporosis and recent low-trauma hip fracture. In glucocorticoid-induced osteoporosis, there is no significant difference between Zol and risedronate for new fractures. Improvements in bone mineral density and early reduction of bone remodeling markers are observed in postmenopausal osteoporosis, recent low-trauma hip fracture, and glucocorticoid-induced osteoporosis. Given that Zol is generally well tolerated and very convenient, it is an interesting therapeutic option for aging patients who take multiple oral drugs, who have adherence or gastrointestinal tolerance issues, and who have an indication for oral bisphosphonates. Zol is not recommended for patients with severe renal impairment. Vitamin D deficiency should be corrected before the administration of Zol.

Overcoming problems with adherence to osteoporosis medication

Nonadherence to pharmacological treatment in osteoporosis is a well-recognized problem. As in other chronic diseases, adherence to osteoporosis treatment is poor, resulting in enormous burden on patients and healthcare resources. Most importantly, low adherence rates consistently result in increased rates of fractures. However, it seems that efforts to evaluate and improve rates of both compliance and persistence are increasing. The extension of dosing intervals may be an element, among others, allowing improvements in therapeutic adherence. Improved patient education, enhancing healthcare provider-patients interaction, taking into account patient's preferences and involving them in treatment decisions may improve adherence.

Knowledge about osteoporosis in postmenopausal women undergoing antiresorptive treatment

A good understanding and knowledge of osteoporosis is a prerequisite for the success of preventive measures as well as treatment adherence.

OBJECTIVE

To assess knowledge about osteoporosis in postmenopausal women with osteoporosis or osteopenia undergoing antiresorptive treatment.

SUBJECTS AND METHODS

A cross-sectional study was based on a sample of 232 postmenopausal women with osteopenia or osteoporosis diagnosed by bone density studies and seen at the Menopause Outpatient Clinic at Caism/Unicamp. Women's knowledge of osteoporosis was assessed by means of the OPQ (Osteoporosis questionnaire), a 20-item questionnaire about osteoporosis in areas of general information, risk factors, consequences and treatment.

RESULTS

The average age of the women was 61.6 years (±8.2 years) and the average time since menopause was 16.8 years. The average knowledge score obtained by the OPQ was 3.78. The average score for correct answers was 9.8 points, while the average score for incorrect answers was 6 points and 'don't know' answers was 4.1 points. Bivariate analysis showed the variables most closely associated with greater knowledge: education (p<0.01), reading (p<0.02), socioeconomic status (p<0.03), means of acquiring osteoporosis medication (p<0.02), and absence of comorbidities (p<0.04). On multiple regression analysis, the factors which remained associated with better knowledge were higher education, higher socioeconomic status scores and absence of comorbidities.

CONCLUSION

Knowledge of osteoporosis in postmenopausal women diagnosed with the disease was limited. Level of education was a strong predictor of knowledge.

Efficacy, side effects and route of administration are more important than frequency of dosing of anti-osteoporosis treatments in determining patient adherence: a critical review of published articles from 1970 to 2009

The purposes of the study were to review available published literature on magnitude of non-adherence with osteoporosis regimens and to determine the association between frequency and modality of medication administration with patient preference and adherence. We searched peer-reviewed journal databases--MEDLINE, EMBASE, Biosis and Derwent Drug File for publications (January 1979 to January 2009) including MeSH terms--"patient preference", "adherence" and "compliance" based on "dosing frequency" and "modality". Since adherence was difficult to accurately quantify, preference, compliance and persistence were evaluated. Patients' preference and adherence at 12 months were higher with weekly over daily bisphosphonates (≥ 84% preference for weekly, medication possession ratios (MPR) 60-76% vs 46-64%; persistence 43.6-69.7% vs 31.7-55.7%). MPR reported for oral bisphosphonates were 68-71% at 12 months. At 2 years, only 43% of patients had MPR ≥ 80% for daily and weekly bisphosphonates. Observational studies (6-12 months) reported discontinuation rates of 18-22% for daily and 7% for weekly bisphosphonates. Data on monthly bisphosphonates are conflicting and confounded by cost differences, patient support programmes and definition of persistence. Studies suggest patient preference for annual zoledronic acid infusions over weekly bisphosphonates (66.4-78.8% vs 9.0-19.7%, respectively), but no data on compliance or persistence are available. Drug effectiveness, side effects and route of administration were more important than frequency. Although less frequent dosing is preferred, other factors such as perceived efficacy, side effects, medication cost, availability of patient support programmes and route of delivery are equally important. Adherence is complex and difficult to quantify and may not be exclusively influenced by frequency of medication administration.

In vivo bone augmentation in an osteoporotic environment using bisphosphonate-loaded calcium deficient apatite

Resorbable calcium phosphate (CaP) biomaterials have demonstrated considerable efficacy in bone reconstructive surgery. Furthermore, bisphosphonates (BPs) are well known anti-resorptive agents largely used in clinical treatments for osteoporosis. An injectable BP-combined CaP matrix has been developed in order to biologically reinforce osteoporotic bone by increasing the bone fraction and improving bone micro-architecture. Our previous in vitro studies have shown that CaP is effective for loading and releasing BPs at doses that can inhibit excessive bone resorption without affecting osteoblasts. In vivo studies in relevant animal models are necessary to explore the effect of our injectable BP-combined biomaterial on femur bone structure by performing three-dimensional microtomography analysis, histological studies and SEM observations. Firstly, in rat model, our BP-combined CaP matrix significantly improved the bone micro-architecture as compared to CaP alone. The implantation of the BP-loaded biomaterial within proximal femurs of osteoporotic ewes led to a significant increase in relative bone content and an improvement of its micro-architecture. These modifications were confirmed by histological and SEM observations, which revealed CaP granule resorption and new bone trabeculae formation. This approach could be considered in the future for preventing osteoporotic fractures that are preferentially localized in the proximal femur, vertebral bodies or wrist.

Oral bisphosphonate compliance and persistence: a matter of choice?

Compliance to oral bisphosphonates is suboptimal, with negative consequences of increased healthcare utilization and less effective fracture risk reduction. Extending dose interval increased adherence only moderately. We used literature derived from multiple chronic conditions to examine the problem of noncompliance with osteoporosis medication. We reviewed the literature on adherence to osteoporosis medication as well as that across multiple chronic conditions to understand what is known about the cause of the poor adherence. Poor compliance to oral medications is due mostly, not to forgetfulness, but to deliberate choice. Gender differences and style of healthcare management also play a role. Preliminary data suggest psychobehavioral interventions may help to improve motivation. We need to understand better reasons for poor compliance before effective interventions can be developed. Forgetfulness is only a small part of poor compliance. Patient preferences must be considered in medication decision making.

Fracture Incidence, Quality of Life, and Back Pain during 18-Months Treatment with Teriparatide in Greek Postmenopausal Women with Osteoporosis: Results from the European Forsteo Observational Study

Objective. To evaluate fracture incidence, effects on health-related quality of life(QoL), back pain (BP) occurrence and treatment compliance in Greek post-menopausal osteoporotic women treated with teriparatide (TPTD) for up to 18 months, in a naturalistic setting. Methods. 301 patients provided baseline information on demographic characteristics, fracture history, osteoporosis-related medication and risk factors. During treatment, QoL and BP severity were evaluated. Results. Mean (SD) age was 69.5 (±8.5) years. Fracture history was reported by 92.5% of patients. Incidence of fractures (per 10,000 patients/years) ranged from 402 during 0-6 months of treatment, to 346 during 12-18 months. All 5 dimensions of QoL showed improvement. At baseline and 18 months, BP was reported by 93.2% and 64.2% of patients, respectively. BP and limitation of activities were quantified as moderate or severe by 89.9% and 62.3% of patients at baseline versus 32.4% and 14.8% at 18 months. Patients on treatment at 6, 12, 17, and 18 months were 92.6%, 88.3%, 79.6%, and 36.5%, respectively. Conclusions. In the Greek EFOS study cohort, patients prescribed TPTD were severely osteoporotic, with considerable health-related problems. Significant improvements in QoL and BP together with low fracture rates and high compliance have been recorded during treatment.

Factors Associated with Persistence with Teriparatide Therapy: Results from the DANCE Observational Study

Purpose. Determine patient-reported reasons for discontinuation with teriparatide. Methods. Patients taking teriparatide in a multicenter, prospective, and observational study were given three questionnaires: baseline, follow-up questionnaire 1 (QF1, 2 to 6 months), and follow-up questionnaire 2 (QF2, 12 months). Discontinuation reported at QF1 and QF2 was defined as "early" and "late," respectively, and remaining patients were considered persistent. Cochran-Armitage trend test was used to identify factors associated with discontinuation. Results. Side effects, concern about improper use, injection difficulties, and several patient-perceived physician issues were associated with early discontinuation. Low patient-perceived importance of continuing treatment, side effects, difficulty paying, and low patient-perceived physician knowledge were associated with late discontinuation. The most common specific reasons selected for discontinuing treatment were "concerns about treatment outweighing the benefits" (n = 53) and "difficulty paying" (n = 47). Conclusions. Persistence with teriparatide is dependent on managing side effects, addressing financial challenges, proper training, and obtaining support from the healthcare provider.

Clinical use of denosumab for the treatment for postmenopausal osteoporosis

Denosumab is a fully human monoclonal antibody with high affinity and specificity for human receptor activator of nuclear factor kappa B ligand (RANKL), the principal regulator of osteoclastic bone resorption. By binding to RANKL, denosumab prevents it from binding to its receptor on the cell surface of pre-osteoclasts and mature osteoclasts, thereby reducing the formation, activity, and survival of osteoclasts and inhibiting osteoclastic bone resorption. In a large, randomized, placebo-controlled clinical trial in postmenopausal women with osteoporosis, denosumab 60 mg administered subcutaneously every 6 months reduced levels of bone turnover markers, increased bone mineral density, and reduced the risk of vertebral fractures, hip fractures, and non-vertebral fractures. There was no significant difference between denosumab and placebo in the overall risk of adverse events or serious adverse events. Denosumab was associated with a significant increase in the risk of eczema and cellulitis, and a significant decrease in the risk of falling and concussions. Denosumab recently received regulatory approval for the treatment of postmenopausal women with osteoporosis at high risk for fracture, with no dose adjustment in patients with renal impairment. Denosumab is a new therapeutic option to reduce fracture risk in women with postmenopausal osteoporosis, especially for those with impaired renal function or with intolerance or poor response to oral therapy.

Positive impact of compliance to strontium ranelate on the risk of nonvertebral osteoporotic fractures

SUMMARY

Adherence is now one of the major issues in the management of osteoporosis. This paper relates the relationship existing between adherence to strontium ranelate and the risk of subsequent nonvertebral fracture among postmenopausal women with osteoporosis.

INTRODUCTION

The aim of this study is to investigate compliance to strontium ranelate (SR) therapy and the impact of compliance on the risk of nonvertebral fractures among women with osteoporosis.

METHODS

This study was a post-hoc analysis of pooled data from two international, phase III, randomized, placebo-controlled, double-blind studies (the Spinal Osteoporosis Therapeutic Intervention and Treatment Of Peripheral Osteoporosis). A nested case-control study was performed in the strontium ranelate-treated population. Compliance was quantified using the medication possession ratio (MPR).

RESULTS

Two hundred eighty-five nonvertebral fracture cases (hip fx n = 70; major nonvertebral fx n = 213) were identified and matched to 1,425 controls. The mean MPR was 86.8% for controls and 82.6% for cases (p < 0.001). Women who were compliant to SR had a 38% reduction in all nonvertebral fractures compared with those who were not (OR = 0.62; 95%CI[0.47-0.81; p < 0.001). Considering hip fractures only, the risk was reduced by 50% for compliant patients compared to noncompliant patients (OR = 0.50; 95%CI[0.28-0.88]; p < 0.05).

CONCLUSION

Our analyses emphasize the importance of good compliance to treatment in order to reduce the risk of osteoporotic fractures. In particular, there was a greater reduction in the risk of nonvertebral and hip fractures with increase compliance.

Adherence and persistence in patients with postmenopausal osteoporosis treated with raloxifene

OBJECTIVE

A major impediment in osteoporosis care is poor therapeutic adherence. Real-life surveys show that adherence and persistence with oral bisphosphonates decrease to 30-60% within 1 year. The aim of this study was to analyze the adherence and persistence with raloxifene in patients visiting our outpatient clinic.

MATERIAL AND METHODS

A total of 342 patients were evaluated from the conventional osteoporosis practice receiving treatment with raloxifene. Patient self-reporting was combined with the medication possession ratio (MPR) assessed via prescription refill counts. In addition, persistence and other self-reported and patient file-based data were assessed.

RESULTS

The final analysis comprised 300 patients with a mean age of 66.3 years (standard deviation ± 7.2 years). At 6 months 84%, at 12 months 81%, at 24 months 78% and at 36 months 77% of patients were persistent with therapy according to patients' self-reports. If MPR and self-reported data were combined, 56%, 48% and 35% of patients remained on therapy at 12, 24 and 36 months, respectively. The mean duration of therapy was 19 months with a mean MPR of 52.8%. Finally, 31.7% of all patients were classified as adherent. Significant correlation to adherence was found for tolerability and motivational factors.

CONCLUSION

This study revealed that approximately half of the patients treated with raloxifene in regular clinical practice stay on therapy for the first 2 years. Furthermore, the patients do not adhere sufficiently to the recommended dosage, and reduced clinical efficacy in clinical practice is presumable. The reasons for non-adherence comprise tolerability and motivational factors but further investigation is needed.

Risk communication and shared decision making in the care of patients with osteoporosis

Health maintenance and disease management require vigilance in assessing risk, communicating risk, and balancing the expected benefits of therapeutic interventions with potential harms. The evaluation of skeletal health includes identification of clinical risk factors for fracture, bone density testing in appropriate patients, and the use of validated algorithms for estimating the probability of fracture. To reduce the burden of osteoporotic fractures, patients at risk for fracture must be identified and treated with effective agents that are taken regularly, correctly, and for a sufficient length of time to achieve the desired benefit. These goals may be enhanced by shared decision making, a process by which the clinician and the patient share all applicable information and negotiate a plan of treatment that is acceptable to both. As an educator and a partner in making treatment decisions, the clinician must be familiar with the medical evidence and able to discuss complex medical information in a manner that is understood by the patient, with appropriate consideration of the patient's expectations, beliefs, and concerns. After treatment is started, risk communication, patient education, and shared decision making should be continued in an effort to maintain good compliance and persistence with therapy. Further study is needed to identify and validate optimal risk communication tools for the care of patients with osteoporosis. Challenges to shared decision making include competition from other health care priorities for limited patient encounter time during office visits, poor reimbursement, insufficient knowledge of the medical evidence, inadequate communication skills, and cognitive/affective disorders limiting patient participation in making treatment decisions.

Survey of bisphosphonate regimen preferences in an urban community health center

OBJECTIVE

to determine patient preference for bisphosphonate therapy based on dosage form and dosing schedule.

DESIGN

prospective telephone survey.

SETTING

urban community health center.

PATIENTS, PARTICIPANTS

all patients who were seen in the osteoporosis clinic during the 22-month time period were contacted. Patients were excluded if they could not complete the survey in English, had difficulty hearing, had cognitive impairment, or were unable to be reached by telephone.

INTERVENTIONS

patients were asked which route and frequency of bisphosphonate therapy was preferred, convenient, and easiest to remember.

MAIN OUTCOME MEASURE(S)

patient-reported preference for route and frequency of bisphosphonate administration.

RESULTS

ninety patients were included in the final analysis. Preference for bisphosphonate therapy illustrated that equal numbers of respondents preferred either once-monthly or once-yearly regimens (24.4% for each, n = 22). One-third of respondents (n = 30) indicated that a once-yearly infusion was the most convenient method of administration. The survey revealed no strong association of which regimen was easiest to remember.

CONCLUSION

the majority of patients preferred once-monthly or less frequent dosing schedules. Clinicians may consider discussing patient preferences during initiation and throughout therapy.

Long-term safety and efficacy of raloxifene in the prevention and treatment of postmenopausal osteoporosis: an update

The integrity of bone tissue and its remodeling that occurs throughout life requires a coordinated activity of osteoblasts and osteoclasts. The decreased estrogen circulating level during postmenopausal transition, with a prevalence of osteoclastic activity over osteoblastic activity, represents the main cause of bone loss and osteoporosis. Osteoporosis is a chronic disease requiring long-term therapy and it is important to evaluate the efficacy and safety of treatments over several years, as the fear of health risks is a common reason for discontinuing therapy. Raloxifene is a selective estrogen receptor modulator (SERM) leading to estrogen-agonist effects in some tissues and estrogen-antagonist effects in others. Raloxifene is effective to prevent and treat postmenopausal vertebral osteoporosis, with reduction of spine fractures and, in post-hoc analyses, non-spine fractures in high-risk subjects. Moreover, raloxifene reduces the risk of invasive breast cancer and improves the levels of serum lipoprotein but with an increased risk of venous thromboembolism and fatal stroke, without significant change in the incidence of coronary events. For these reasons the overall risk-benefit profile is favorable. Therefore, when considering the use of raloxifene in a postmenopausal woman, we should take into account the osteoporosis-related individual risk and weigh the potential benefits, skeletal and extra-skeletal, against the health risks.

Methods to examine the impact of compliance to osteoporosis pharmacotherapy on fracture risk: systematic review and recommendations

The objective of this study was to review the methods of prior studies that estimate the association between compliance to osteoporosis pharmacotherapy on fracture risk, and make recommendations to guide future research. We completed a systematic search of MEDLINE to identify all English language nonexperimental studies that examined the impact of adherence to osteoporosis pharmacotherapy on fracture risk. Studies that measured compliance were eligible and those that only examined persistence were excluded. We summarized the methodology of each study and make recommendations for future research. We identified 14 eligible articles: nine cohort and five nested case-control. Length of baseline (lookback) periods ranged between 3 months and 2 years, with nearly all studies (86%) restricting inclusion to treatment-naïve users. A threshold of 80% was most commonly used to define compliance (n = 10), with few studies providing a more thorough analysis through categorical (n = 3) or continuous (n = 1) measures. All nine cohort studies adjusted for age, sex, prior fracture, and at least one other comorbidity or drug; two cohort studies adjusted for a comorbidity score. Two of the five case-control studies clearly controlled for age, sex, drug exposure, event date and length of follow up. One study considered a theoretical sensitivity analysis to account for potential healthy adherer bias, yet all mentioned limitations related to possible residual confounding. We identify great variability in methods of prior studies that evaluate the impact of compliance to osteoporosis pharmacotherapy on fracture risk, and make recommendations to guide future research.

[Osteoporosis treatment with biphosphonates: Approaches to care reality]

OBJECTIVE

Osteoporosis predominantly affects menopausal women and has a significant morbidity expressed as fractures. The study aimed to describe the types of bisphosphonates used to treat osteoporosis in post-menopausal women and to establish how treatment non-compliance affects the fracture rate.

DESIGN

Retrospective cohort study of women on active treatment with bisphosphonates for the past five years.

LOCATION

Utebo Health Centre (Zaragoza) (16,000 inhabitants) with a general medical quota of 1,890 patients).

PARTICIPANTS

A total of 129 women who were on active treatment with bisphosphonates for five years were included.

MAIN MEASURES

The distribution by drug was analysed, as well as the percentage of women who did not comply with the treatment correctly and any identified fractures.

RESULTS

A total of 129 women on treatment were identified (13.0% of all women patients): alendronic acid (45.7%), ibandronic acid (21.7%), risedronic acid (19.4%) and alendronic acid plus cholecalciferol (13,2%). 19.4% of women stopped their treatment after at least 3 months. Thirteen hip fractures were identified.

CONCLUSIONS

The overall treatment compliance was 80.6%, Depending on the type of bisphosphonate: alendronic acid plus cholecalciferol (88.2%), risedronic acid (88.0%), alendronic acid (78.0%), ibandronic acid (75.0%). The incidence of hip fractures was similar incidence to that observed with respect to non-compliance to treatment. Lack of therapeutic compliance is common in menopausal women, and measures should be promoted to increase effectiveness as well as to make patients aware of the importance of continuing treatment.

Intravenous zoledronic acid for the treatment of osteoporosis: The evidence of its therapeutic effect

INTRODUCTION

Osteoporosis is a disease characterized by low bone mineral density and poor bone quality resulting in reduced bone strength and increased risk of fracture. Oral bisphosphonates, first-line therapy for most patients with osteoporosis, are associated with suboptimal adherence to therapy due to factors that include a complex dosing regimen and gastrointestinal intolerance in some patients. Intravenous bisphosphonates address these limitations through infrequent injectable dosing that assures 100% bioavailability. Intravenous zoledronic acid is the newest bisphosphonate to be approved for the treatment of osteoporosis.

AIMS

This review assesses the evidence for the therapeutic effects of intravenous zoledronic acid for the treatment of osteoporosis.

EVIDENCE REVIEW

Zoledronic acid 5 mg administered as an annual 15-min intravenous infusion has been shown to reduce the risk of vertebral fractures, hip fractures, and other fractures in a three-year randomized, double-blind, placebo-controlled trial in women with postmenopausal osteoporosis. In a randomized, double-blind, placebo-controlled trial in women and men with a recent surgical repair of low-trauma hip fracture, it reduced the risk of new clinical fractures and improved survival. In both studies, zoledronic acid was associated with a good safety profile and was generally well tolerated. Zoledronic acid has the potential to improve clinical outcomes by reducing the risk of fracture in patients with osteoporosis.

CLINICAL VALUE

Intravenous zoledronic acid 5 mg every 12 months reduces fracture risk in women with postmenopausal osteoporosis and in women and men with recent low-trauma hip fracture.

Longitudinal change in clinical fracture incidence after initiation of bisphosphonates

SUMMARY

There are differences in the risk profile of patients prescribed alendronate, risedronate, or ibandronate. Observed reductions in fracture incidence over time suggest that the effectiveness of each bisphosphonate in clinical practice has been consistent with their efficacies demonstrated in randomized controlled trials.

INTRODUCTION

Observational studies of bisphosphonate effectiveness for fracture prevention are subject to bias from unknown characteristics of baseline fracture risk at the start of therapy. The fracture incidence during the short period after starting a bisphosphonate and before any expected clinical benefit likely reflects baseline fracture risk. Bisphosphonate effectiveness may then be estimated by measuring the change in fracture incidence over time on therapy.

METHODS

Administrative billing data were used to follow three cohorts of women aged 65 and older (total n = 210,144) after starting therapy either on alendronate, risedronate, or ibandronate in the USA between market introduction and 2006. Within each cohort, the baseline incidence of clinical fractures at the hip, vertebral, and nonvertebral sites was defined by the initial 3-month period after starting therapy. Relative to these baselines, we then compared the fracture incidence during the subsequent 12 months on therapy.

RESULTS

At the start of therapy, the ibandronate cohort was younger and had fewer prior fractures than either the risedronate or alendronate cohorts. Accordingly, the baseline incidence of hip fractures was higher in the risedronate cohort (0.90 per 100 person-years) and in the alendronate cohort (0.77) than in the ibandronate cohort (0.64). Relative to the baseline incidence, fracture incidence was significantly lower in the subsequent 12 months in both cohorts of alendronate (18% lower at hip, 28% at nonvertebral sites, and 57% at vertebral sites) and risedronate (27% lower at hip, 21% at nonvertebral sites, and 54% at vertebral sites). In the ibandronate cohort, the fracture incidence was lower (31%) only at vertebral sites.

CONCLUSIONS

Differences in the baseline fracture incidence among the cohorts may reflect differences in the risk profile of patients prescribed each bisphosphonate. The reductions observed in fracture incidence over time within each cohort suggest that the effectiveness of each bisphosphonate in clinical practice has been consistent with their efficacies demonstrated in randomized controlled trials.

Persistence to medical treatment of osteoporosis in women at three different clinical settings - A historical cohort study

Purpose: This study was undertaken to assess persistence with bisphosphonates and raloxifene and to identify determinants of adherence (patient age, level of information, educational status, etc.) among women with osteoporosis in three different clinical settings in Denmark. Methods: We compared persistence to therapy in three historical cohorts of women diagnosed with osteoporosis starting therapy between January 1999 and January 2004. The study comprised 878 patients treated and followed at Odense University Hospital, 285 patients diagnosed and followed at the Hellerup Osteoporosis Clinic (private practice), and 343 patients diagnosed at Aarhus University Hospital and followed by the referring general practitioner. Data on persistence and possible confounders were collected using a mailed questionnaire. Reminders were issued after 1—2 months to non-respondents. Results: Persistence at 2 years as estimated from Kaplan—Meyer analysis was 0.87, 0.84 and 0.88 in the three cohorts, respectively. There were no significant differences between the clinics. Level of persistence was not related to patient assessment of the adequacy of the clinical information provided by the prescribing doctor, presence of prior fractures or a family history of osteoporosis. However, patients who read the information leaflet on their osteoporosis medication tended to be more persistent with treatment (p < 0.09). Conclusions: Women’s persistence with bisphosphonates and raloxifene was surprisingly high and similar between treating centres. This may be due to a high level of public information available on osteoporosis in Denmark.

Management of osteoporosis in postmenopausal women: 2010 position statement of The North American Menopause Society

OBJECTIVE

To update the evidence-based position statement published by The North American Menopause Society (NAMS) in 2006 regarding the management of osteoporosis in postmenopausal women.

METHODS

NAMS followed the general principles established for evidence-based guidelines to create this updated document. A panel of clinicians and researchers expert in the field of metabolic bone diseases and/or women's health was enlisted to review the 2006 NAMS position statement, compile supporting statements, and reach consensus on recommendations. The panel's recommendations were reviewed and approved by the NAMS Board of Trustees.

RESULTS

Osteoporosis, which is especially prevalent among older postmenopausal women, increases the risk of fractures. Hip and spine fractures are associated with particularly high morbidity and mortality in this population. Given the health implications of osteoporotic fractures, the primary goal of osteoporosis therapy is to prevent fractures, which is accomplished by slowing or stopping bone loss, maintaining bone strength, and minimizing or eliminating factors that may contribute to fractures. The evaluation of postmenopausal women for osteoporosis risk requires a medical history, physical examination, and diagnostic tests. Major risk factors for postmenopausal osteoporosis (as defined by bone mineral density) include advanced age, genetics, lifestyle factors (such as low calcium and vitamin D intake, smoking), thinness, and menopause status. The most common risk factors for osteoporotic fracture are advanced age, low bone mineral density, and previous fracture as an adult. Management focuses first on nonpharmacologic measures, such as a balanced diet, adequate calcium and vitamin D intake, adequate exercise, smoking cessation, avoidance of excessive alcohol intake, and fall prevention. If pharmacologic therapy is indicated, government-approved options are bisphosphonates, selective estrogen-receptor modulators, parathyroid hormone, estrogens, and calcitonin.

CONCLUSIONS

Management strategies for postmenopausal women involve identifying those at risk for fracture, followed by instituting measures that focus on reducing modifiable risk factors through dietary and lifestyle changes and, if indicated, pharmacologic therapy.

Bisphosphonates for the treatment of osteoporosis: insights for clinicians

Osteoporosis is a common skeletal disease characterized by a reduction in bone strength and increased risk of fractures. Osteoporotic fractures are associated with substantial morbidity, mortality, and high healthcare costs. Treatments for osteoporosis have been shown to increase bone strength and reduce fracture risk. The drugs most commonly used to treat osteoporosis are bisphosphonates: stable analogs of naturally occurring inorganic pyrophosphate. The bisphosphonates share a common chemical structure with side chain variations that convey differences in their pharmacological properties, such as affinity for bone mineral and inhibitory effect on osteoclastic bone resorption. The clinical profiles of bisphosphonates, such as time of onset and offset of effect, may differ according to these pharmacological properties. Bisphosphonates can be administered orally or intravenously with a wide range of doses and dosing intervals. Randomized placebo-controlled clinical trials have shown that bisphosphonates reduce fracture risk in postmenopausal women with osteoporosis and have a generally excellent safety record. Clinical challenges in using bisphosphonates to treat osteoporosis include appropriate selection of patients for initiating therapy, choosing which bisphosphonate to use, monitoring therapy to assure that medication is taken correctly and the desired effect is achieved, determining when drug discontinuation should be considered, and managing side effects, possible side effects, and fear of side effects. Strategies for treating patients with bisphosphonates should consider each of these issues.

Preference and satisfaction with a 6-month subcutaneous injection versus a weekly tablet for treatment of low bone mass

The Preference and Satisfaction Questionnaire (PSQ) compares patient preference and satisfaction between a 6-month subcutaneous injection and weekly oral tablet for treatment of bone loss. Patients preferred and were more satisfied with a treatment that was administered less frequently, suggesting the acceptability of the 6-month injection for treatment of bone loss.

INTRODUCTION

The PSQ compares patient preference and satisfaction between a 6-month subcutaneous injection and a weekly oral tablet for treatment of bone loss.

METHODS

Postmenopausal women with low bone mass who enrolled in two separate randomized phase 3 double-blind, double-dummy studies received a 6-month subcutaneous denosumab injection (60 mg) plus a weekly oral placebo or a weekly alendronate tablet (70 mg) plus a 6-month subcutaneous placebo injection. After 12 months, patients completed the PSQ to rate their preference, satisfaction, and degree of bother with each regimen.

RESULTS

Most enrolled patients (1,583 out of 1,693; 93.5%) answered >or=1 item of the PSQ. Significantly more patients preferred and were more satisfied with the 6-month injection versus the weekly tablet (P < 0.001). More patients reported no bother with the 6-month injection (90%) than the weekly tablet (62%).

CONCLUSION

Patients preferred, were more satisfied, and less bothered with a 6-month injection regimen for osteoporosis.

Denosumab--an emerging treatment for postmenopausal osteoporosis

IMPORTANCE OF THE FIELD

Osteoporosis is a common skeletal disease that is associated with an imbalance in bone remodeling. Denosumab is an investigational fully human monoclonal antibody to receptor activator of NF-kappaB ligand (RANKL), a cytokine member of the TNF family that is the principal mediator of osteoclastic bone resorption.

AREAS COVERED IN THIS REVIEW

The efficacy and safety of denosumab in the management of postmenopausal osteoporosis is evaluated by reviewing the published literature and presentations at scientific meetings through 2009.

WHAT THE READER WILL GAIN

This review focuses on the data on fracture risk reduction and safety endpoints of denosumab in the treatment of postmenopausal osteoporosis.

TAKE HOME MESSAGE

In postmenopausal women with osteoporosis, denosumab (60 mg by subcutaneous injection every 6 months) increased bone mineral density, reduced bone turnover markers, and reduced the risk of vertebral, hip and non-vertebral fractures. Denosumab was well tolerated with a safety profile generally similar to placebo. It is a promising emerging drug for the prevention and treatment of postmenopausal osteoporosis.

Physician perception of patient adherence compared to patient adherence of osteoporosis medications from pharmacy claims

OBJECTIVE

This study explored physicians' perceptions of patient adherence to medications compared with patient adherence derived by administrative data in the treatment of osteoporosis.

RESEARCH DESIGN AND METHODS

A study involving written questionnaires from prescribers treating patients with postmenopausal osteoporosis (PMO) compared the questionnaire responses to pharmacy claims of these prescribers' patients' refill patterns. Approximately 2000 physicians from a large US health plan were faxed or mailed a survey. Data from the physician survey were merged with administrative claims data of the participating physicians' patients.

RESULTS

A total of 412 physicians (21.8%) responded. Although a low response rate, there were no significant demographic differences between participating and non-participating physicians. Surveyed physicians reported that 66% of their patients had private/commercial coverage and over 60% reported seeing their PMO patients annually. Overall, physicians estimated that 69.2% of patients were adherent 80% of the time after 12 months of therapy. Yet, pharmacy claims data for those physicians' patients indicated 48.7% of patients were adherent (defined as having an MPR of >or=80%) after 12 months of therapy. Physicians overestimated their patients' adherence regardless of medication class and across physician specialties. Regression modeling revealed that physicians who have been in practice longer estimated fewer patients as adherent, whereas those who prescribe more PMO treatments estimate a greater number of patients as adherent. Providers cited side effects and affordability of medication as the most frequent reasons for non-adherence.

CONCLUSIONS

Physicians overestimate patient adherence to PMO therapies. Improving physician awareness of medication non-adherence to PMO therapies may facilitate physician-patient dialogue, with the aim of identifying patient-centered reasons for non-adherence. These discussions are important because patients with poorer adherence have a higher risk of fracture. Future research should focus on reasons for patient non-adherence to osteoporosis regimens and intervention strategies that improve communication between the provider and patient. Findings must be considered within the limitations of this claims database analysis. Some degree of incomplete or incorrect coding may exist, and the presence of a claim for a filled prescription does not indicate that the medication was consumed or taken as prescribed. Patients included in the study are not necessarily representative of all patients being treated for osteoporosis.

Bisphosphonates and osteoporotic fractures: a cross-design synthesis of results among compliant/persistent postmenopausal women in clinical practice versus randomized controlled trials

In a cross-design synthesis, total fractures were similarly reduced by bisphosphonates among postmenopausal women in randomized trials (23.8%) and highly compliant/persistent patients in observational studies of large databases from routine practice (20.3%). Bisphosphonates also reduced nonvertebral, vertebral and hip fractures in randomized trials and observational studies. In the real-word setting, compliant/persistent patients can gain a benefit from bisphosphonates comparable to that of randomized trial participants.

INTRODUCTION

The purpose of the study was to determine whether clinical fracture risk reduction by bisphosphonate treatment in women with postmenopausal osteoporosis differs between randomized controlled trials and routine practice.

METHODS

Randomized trials comparing bisphosphonate with placebo and observational studies comparing highly compliant/persistent with less compliant/persistent patients were sought by electronic searches and ancillary methods. Clinical fracture data were extracted from the study reports and quantitatively combined by random effects metaanalysis.

RESULTS

The odds ratio (OR) for all clinical fractures in randomized trials of 0.762, with a 95% confidence interval (CI) of 0.680-0.855, was closely similar to that in the observational studies (OR, 0.797; CI, 0.748-0.850). Pooled clinical fracture reduction across both study designs was 22%. Nonvertebral, vertebral, and hip fractures were also significantly reduced by bisphosphonate treatment in both randomized trials and observational studies.

CONCLUSIONS

Compliant/persistent patients in the "real-world" setting benefit from bisphosphonate treatment to a similar extent as patients in randomized trials.

Adherence and persistence in patients with severe osteoporosis treated with teriparatide

INTRODUCTION

Medical intervention plays a key role in the treatment of postmenopausal osteoporosis and patients' adherence to therapy is essential for optimal clinical outcomes. While adherence in RCTs is usually around 70-90%, a previous study showed that in clinical practice only 27.8% and 46.5% of the women on oral daily vs. weekly alendronate were still on treatment after 12 months. Data on adherence to teriparatide (TPTD) treatment of severe postmenopausal osteoporosis are available from only few countries. This study assessed adherence and persistence with TPTD in Germany.

MATERIAL AND METHODS

A sample of 50 women with severe postmenopausal osteoporosis treated with TPTD in accordance to the German osteoporosis guidelines was included. Treatment was initiated 12-24 months before recruitment. Patient self report was assessed using a validated questionnaire. In addition medication possession ratio (MPR) was calculated by counting prescription refills, and therefore all physicians who were treating the patients for any disease were contacted. Patients were classified adherent at 12 months of therapy if self-reported adherence and an MPR of > or =80% were achieved. Persistence was calculated in months and analysed with a Kaplan-Meier estimate.

RESULTS

Apart from a significantly lower age at menopause in the adherent group (46.1 vs. 50.0; p < 0.006) there were no significant differences in baseline demographics between adherent and non-adherent patients. After 12 months, 80% of the patients treated with TPTD were adherent, while 20% were non-adherent. A significant correlation with treatment adherence was found for self-reported medication tolerability (p < 0.001). Furthermore 79% of patients were persistent after 12 months.

CONCLUSION

These results indicate that more patients seem to be adherent and persistent with TPTD than with oral treatments of postmenopausal osteoporosis. As these patients suffered from severe osteoporosis and sustained several fragility fractures, the generalisability of our retrospective study analysing a small sample is limited. The major factor that reduced adherence and persistence was tolerability. These findings are of practical relevance as numerous studies on antiresorptive therapies have shown that high adherence and persistence were needed to ensure an optimal therapeutic outcome.

Medication nonfulfillment rates and reasons: narrative systematic review

BACKGROUND

The literature on nonfulfillment of prescription medications spans over three decades of work. There is a wide variation in reported nonfulfillment rates, but no previous study has systematically reviewed this literature to explore the reasons behind this variation.

OBJECTIVE

The objective of this study was to review estimates of medication nonfulfillment rates and published reasons for nonfulfillment and explore whether nonfulfillment rates vary by study variables.

METHODS

Articles were identified through searches conducted on MEDLINE, CINAHL, Psych Info, and EMBASE, and review of relevant reference citations. Methodological variables, nonfulfillment rate, and unit of analysis (i.e., patient or prescription) were abstracted from each article selected for review. Mean and median nonfulfillment rates for groups categorized by unit of analysis and selected methodological variables (method for assessing nonfulfillment, sample characteristics, disease subgroup, sample size, country of data collection, recall period or time allowed before classifying as nonfulfillment, and year of study) were calculated. Reasons for nonfulfillment were abstracted from all articles that included a relevant discussion.

FINDINGS

A total of 79 studies reporting pure nonfulfillment rates (59 at the patient level and 20 at the prescription level) and six studies reporting nonfulfillment rates in combination with nonpersistence rates were included. There was a wide variation in nonfulfillment rates reported by the studies - from 0.5% to 57.1%. The three primary reasons for nonfulfillment identified from this review were perceived concerns about medications, lack of perceived need for medications, and medication affordability issues.

CONCLUSION

To the best of the authors' knowledge, this study is the first narrative systematic review on nonfulfillment of prescription medications. Despite the wide variation in individual study rates, the mean and median rates across different modes of data collection and sources of data were in a relatively narrow range (11% to 19%) and surprisingly close to the overall mean (16.4%) and median (15%.0) rates for all studies. The reasons for nonfulfillment identified through this review address barriers to nonfulfillment at the patient, physician, and health system level and thus bear important implications for policy makers.

Current and emerging pharmacologic therapies for the management of postmenopausal osteoporosis

Postmenopausal osteoporosis is an asymptomatic skeletal disease that is often underdiagnosed and undertreated. Osteoporotic fractures are associated with substantial morbidity and mortality and impaired quality of life-socially, emotionally, and financially. Considering the growing burden of osteoporotic fractures worldwide, there remains an ongoing need for progress in the diagnosis of osteoporosis, identification of individuals at high fracture risk, and treatment to prevent fractures. Adequate intake of calcium and vitamin D is recommended as baseline therapy for osteoporosis prevention and treatment. Available pharmacological agents for the management of postmenopausal osteoporosis may not be appropriate for all women. Oral bisphosphonates are generally considered first-line therapy for patients with osteoporosis, but their use may be limited by gastrointestinal side effects. Other agents include hormone therapy, the selective estrogen receptor modulator (SERM) raloxifene, salmon calcitonin, teriparatide (human recombinant parathyroid hormone), and strontium ranelate (in some countries). Factors that may contribute to poor compliance and persistence with current osteoporosis therapies include drug intolerance, complexity of dosing regimens, and poor understanding of the relative benefit and risk with treatment. Emerging therapies for postmenopausal osteoporosis include novel SERMs (bazedoxifene, lasofoxifene, ospemifene, arzoxifene) and denosumab. Because SERMs can display mixed functional estrogen receptor agonist or antagonist activity depending on the target tissue, they may confer beneficial effects on bone with limited stimulation of other tissues (e.g., breast, endometrium). Clinical investigation of these promising new agents is ongoing to evaluate efficacy and safety, with the goal of developing effective strategies to maximize long-term tolerance, compliance, and persistence with therapy.

Determinant factors of osteoporosis patients' reported therapeutic adherence to calcium and/or vitamin D supplements: a cross-sectional, observational study of postmenopausal women

BACKGROUND

Among the various treatments for osteoporosis, calcium and/or vitamin D supplements are frequently included.

OBJECTIVE

The objective of the study was to analyse adherence to calcium and/or vitamin D treatment and to identify related predictors of non-adherence in a sample of postmenopausal women treated for osteoporosis in primary care.

METHODS

A cross-sectional, observational study was conducted in a sample of postmenopausal women receiving pharmaceutical treatment for osteoporosis with vitamin D and/or calcium. Sociodemographic, general and osteoporosis-related data were collected. Patient's perceptions of the adverse effects of treatment, their knowledge of osteoporosis (Batalla test), their attitude towards treatment (Morisky-Green test) and their self-reported therapeutic adherence (Haynes-Sackett test) were assessed.

RESULTS

Of 630 women (mean age +/- SD 64.1 +/- 8.7 years) evaluated, 36.2% (95% CI 32.4, 39.9) had problems with treatment tolerability, 63.5% (95% CI 59.7, 67.3) had good knowledge of osteoporosis, 20.5% (95% CI 17.3, 23.6) had a good attitude to treatment and 50.0% (95% CI 46.1, 53.9) had good self-reported adherence to treatment. Patients in the poor adherence group had higher mean body mass index (p = 0.014), more concurrent pathologies (p = 0.003), more tolerability problems (p < 0.001) and worse attitude to treatment (p < 0.001). The multivariate model showed a positive relationship between therapeutic adherence and good attitude to treatment (odds ratio [OR] = 11.7; p < 0.001), not having tolerability problems (OR = 3.3; p < 0.001) and no polymedication (OR = 0.80; p = 0.017).

CONCLUSIONS

Only one in two postmenopausal women with osteoporosis who take calcium and/or vitamin D have good self-reported therapeutic adherence to this treatment. Determinant factors of adherence to calcium and/or vitamin D treatment were patient's attitude to the treatment, tolerability problems with the treatment and number of concurrent treatments.

Adherence to monthly and weekly oral bisphosphonates in women with osteoporosis

This primary care database survey evaluated whether osteoporotic women treated with bisphosphonates were more adherent to monthly than to weekly treatment. Both compliance (medication possession ratio [MPR]) and persistence (time to discontinuation) were superior in the monthly ibandronate treatment group. Better control of fracture risk may thus be achieved using monthly treatment regimens.

INTRODUCTION

Treatment adherence in osteoporosis is poor. The objective of this study was to evaluate whether monthly bisphosphonate treatment provided superior adherence than weekly treatment.

METHODS

We analysed medical claims from a national prescription database (Thales). All women aged >45 years receiving a first prescription of monthly ibandronate or weekly bisphosphonates in 2007 were included. Treatment adherence was monitored from initial prescription until January 2008. Compliance was measured by the MPR and persistence by the time from treatment initiation to discontinuation. Multivariate analysis was used to identify variables independently associated with adherence.

RESULTS

Twelve-month persistence rates were 47.5% for monthly ibandronate and 30.4% for weekly bisphosphonates. Compliance was significantly higher in the monthly cohort (MPR = 84.5%) than in the weekly cohort (MPR = 79.4%). After adjustment for potential confounding variables, women with monthly regimens were 37% less likely to be non-persistent (HR = 0.63 [0.56-0.72]) and presented a 5% higher mean MPR (84.5% versus 79.3%, p < 0.001) than women with weekly regimens. Other major factors associated with improved adherence were previous densitometry and calcium or vitamin D supplementation (p < 0.01).

CONCLUSIONS

Adherence to bisphosphonates may be superior for monthly treatment than for weekly treatment and may thus provide improved fracture protection.

Patient preference and acceptability of calcium plus vitamin D3 supplementation: a randomised, open, cross-over trial

Preference for a drug formulation is important in adherence to long-term medication for chronic illnesses such as osteoporosis. We investigated the preference for and acceptability of chewable tablet containing calcium and vitamin D (Calci Chew D₃, Nycomed) compared to that of a sachet containing calcium and vitamin D₃ (Cad, Will-Pharma). This open, randomised, cross-over trial was set up to compare the preference and acceptability of two calcium plus vitamin D₃ formulations (both with 500 mg calcium and 400/440 IU vitamin D3), given twice a day in patients with osteoporosis. Preference and acceptability were assessed by means of questionnaires. Preference was determined by asking the question, which treatment the patient preferred, and acceptability was measured by scoring five variables, using rating scales. Of the 102 patients indicating a preference for a trial medication, 67% preferred the chewable tablet, 19% the sachet with calcium and vitamin D_3, and 15% stated no preference. The significant preference for Calci Chew D₃ (p < 0.0001) was associated with higher scores for all five acceptability variables. The two formulations were tolerated equally well. A significant greater number of patients considered the chewable tablet as preferable and acceptable to the sachet, containing calcium and vitamin D₃. Trial registration: Current Controlled Trials ISRCTN18822358.

Osteoporosis management: a perspective based on bisphosphonate data from randomised clinical trials and observational databases

AIMS

The efficacy of treatments for osteoporosis can be evaluated using a variety of study designs. This article aims to comprehensively review the evidence for bisphosphonate anti-fracture efficacy in postmenopausal women, discussing the strengths and limitations associated with each study method.

METHODS

Literature analysis included English-language publications reporting results of randomised controlled trials (RCTs), post hoc analyses, meta analyses and observational studies evaluating the efficacy of alendronate (ALN), ibandronate (IBN), risedronate (RIS) and zoledronate (ZOL), with an initial sample size > or = 100 patients, and follow-up data for at least 1 year.

RESULTS

Primary and secondary analyses of RCT data suggest differences among bisphosphonates with regard to site-specific anti-fracture efficacy and onset of fracture risk reduction. While some observational studies indicate differences in clinical outcomes among these agents, others report similar effectiveness. ALN and RIS data demonstrate sustained fracture protection for up to 10 and 7 years of treatment respectively. The efficacy of IBN and ZOL has been evaluated for up to 3 and 5 years respectively.

CONCLUSIONS

Understanding of the benefits of bisphosphonate treatment can be maximised by evaluating complementary data from RCTs and observational database studies. Fracture risk reduction with bisphosphonates is shown in RCTs and in real-world clinical settings.

Reduction in fracture rate and back pain and increased quality of life in postmenopausal women treated with teriparatide: 18-month data from the European Forsteo Observational Study (EFOS)

The European Forsteo Observational Study was designed to examine the effectiveness of teriparatide in postmenopausal women with osteoporosis treated for up to 18 months in normal clinical practice in eight European countries. The incidence of clinical vertebral and nonvertebral fragility fractures, back pain, and health-related quality of life (HRQoL, EQ-5D) were assessed. Spontaneous reports of adverse events were collected. All 1,648 enrolled women were teriparatide treatment-naive, 91.0% of them had previously received other anti-osteoporosis drugs, and 72.8% completed the 18-month study. A total of 168 incident clinical fractures were sustained by 138 (8.8%) women (821 fractures/10,000 patient-years). A 47% decrease in the odds of fracture in the last 6-month period compared to the first 6-month period was observed (P < 0.005). Mean back pain VAS was reduced by 25.8 mm at end point (P < 0.001). Mean change from baseline in EQ-VAS was 13 mm by 18 months. The largest improvements were reported in the EQ-5D subdomains of usual activities and pain/discomfort. There were 365 adverse events spontaneously reported, of which 48.0% were considered related to teriparatide; adverse events were the reason for discontinuation for 79 (5.8%) patients. In conclusion, postmenopausal women with severe osteoporosis who were prescribed teriparatide in standard clinical practice had a significant reduction in the incidence of fragility fractures and a reduction in back pain over an 18-month treatment period. This was associated with a clinically significant improvement in HRQoL. Safety was consistent with current prescribing information. These results should be interpreted in the context of the open-label, noncontrolled design of the study.

Poor adherence to oral bisphosphonate treatment and its consequences: a review of the evidence

Poor therapeutic adherence is a major issue faced by physicians today. This paper summarizes the adherence rates with oral bisphosphonate (OBP) treatment in clinical practice and their impact on clinical outcomes. Studies systematically demonstrated that overall compliance and persistence with OBPs among osteoporotic women are poor. Although extending dosing intervals improved adherence, the gains are suboptimal. Most importantly, low compliance and persistence rates consistently resulted in increased rates of fractures. The results emphasize the importance of adherence to treatment to achieve optimal antifracture efficacy. There is an urgent need to implement strategies and to encourage physicians to take measures that increase patients' awareness of the need to use osteoporosis medications as directed in order to benefit from them fully.

Risedronate dosing before breakfast compared with dosing later in the day in women with postmenopausal osteoporosis

Two studies in postmenopausal women with osteoporosis provide information about the efficacy and safety of dosing oral risedronate 5 mg daily at a time other than before breakfast (i.e., 2 h before and 2 h after any food and drink other than plain water). A significant increase in lumbar spine BMD was observed for both treatment regimens in the two studies. However, smaller increases in lumbar spine BMD were observed with flexible dosing versus before-breakfast dosing. Geographic region, compliance, and consistency of dosing time appear to affect the amount of increase in BMD observed with flexible dosing.

INTRODUCTION

Two studies in postmenopausal women with osteoporosis provide additional information about the efficacy and safety of dosing oral risedronate 5 mg daily at a time other than before breakfast (i.e., 2 h before and 2 h after any food and drink other than plain water).

METHODS

One study, flexible dosing, was a 6-month North American study in 730 patients randomized to before-breakfast dosing or flexible dosing later in the day. A second study, IMPACT, was a large (N = 2382), 1-year multinational study in patients that chose their dosing regimen (before breakfast or later in the day). These studies were used to examine the bone mineral density (BMD) response with different dosing regimens.

RESULTS

A significant increase in lumbar spine BMD was observed for both treatment regimens in the two studies. However, in both studies, the flexible dosing group had a smaller increase from baseline compared to the before-breakfast regimen (ratio of flexible dosing to before breakfast: flexible dosing study, 0.52; IMPACT study, 0.75). In addition, a relationship between geographic region and BMD response was observed with flexible dosing in both studies. Patients in the flexible dosing group who had greater dosing compliance (based on the number of times the bottle was opened) and consistency of dosing time (bottle opened within a 1.5-h window) had a greater increase in lumbar spine BMD.

CONCLUSION

Results of these two studies demonstrate that overall flexible dosing of risedronate leads to smaller BMD gains compared to before-breakfast dosing. This result may be due to poorer adherence to the flexible dosing instructions that may be more pronounced in patients in certain geographic regions. If patients cannot abide by before-breakfast dosing and flexible dosing is an approved option, one can expect suboptimal BMD results with flexible dosing.

Clinical efficacy and safety of zoledronic acid in osteoporosis and Paget's bone disease

Osteoporosis and Paget's bone disease are the most common diseases of the bone. In addition to glucocorticoid treatment, there are many other secondary causes of osteoporosis. Bisphosphonates are used to treat these bone conditions. Zoledronic acid is the most potent bisphosphonate at inhibiting bone resorption. In osteoporosis, zoledronic acid increases bone mineral density for at least 1 year following a single intravenous administration. The efficacy and safety of zoledronic acid in the treatment of osteoporosis and Paget's bone disease are reviewed. This article also covers the studies of the effects of zoledronic acid in the bone loss associated with the secondary osteoporosis.

Adherence to weekly oral bisphosphonate therapy: cost of wasted drugs and fractures

In an observational cohort of patients treated with biphosphonates (BP), we observed that poor adherence to these drugs causes important expenditures in terms of avoidable fractures. Of particular interest are the amounts of money wasted by patients who did not take their BPs long enough to obtain a clinical benefit.

INTRODUCTION

A large proportion of patients initiated with oral weekly BP therapy stop their treatment within the first year. The objective of this study was to estimate the impact of the poor adherence to BPs in terms of drug wasted and avoidable fractures.

METHODS

The study was done on primary and secondary prevention cohorts from the Régie de l'assurance maladie du Québec (Québec). The concept of the "point of visual divergence" was used to determine the amount of wasted drug. The risk of fracture was estimated using Cox regression models. The hazard ratios of compliant patients (+80%) versus non compliant patients were used to estimate the number of fractures saved.

RESULTS

The cost of wasted drugs was $25.87 per patient initiated in the primary prevention cohort and $30.52 in the secondary prevention cohort. If all patients had been compliant, 110 fractures would have been avoided in the primary prevention cohort and 19 fractures in the secondary prevention cohort. The cost of these avoidable fractures per patient initiated on BP therapy was $62.95 in primary prevention cohort and $330.84 in secondary prevention cohort.

CONCLUSIONS

This study confirms that poor adherence to oral BPs leads to a significant waste of money and avoidable fractures.

Differences in persistence among different weekly oral bisphosphonate medications

SUMMARY

We evaluated the differences in persistence with weekly oral bisphosphonate therapy according to the initial drug. Persistence to weekly oral preparations remains suboptimal, particularly in patients who receive generic alendronate. Alternative solutions are needed to improve the real life effectiveness of osteoporosis therapies.

INTRODUCTION

Poor persistence is widespread with oral osteoporosis (OP) therapy. The objective of this study was to evaluate the persistence among OP patients started on weekly oral bisphosphonates (BP).

METHODS

Patients newly initiated on branded risedronate, branded alendronate, or generic alendronate once weekly were selected from the Régie de l'Assurance Maladie du Québec databases. The cohort included patients with and without a previous OP fracture. The probability and the risk factors for early discontinuation were estimated using Cox regression models.

RESULTS

The study cohort included 32,804 patients. After 1 year, a significant difference in persistence on oral BP therapy was found. The patients started on branded risedronate were 11% more likely to stop OP therapy than patients started on branded alendronate. Risk of discontinuation doubled in patients initiated with generic alendronate compared to patients started on branded alendronate. Male gender was associated with a 25% increase risk of early discontinuation. No statistical association was found between previous OP fracture and early discontinuation.

CONCLUSION

This study provides further evidence of poor persistence to newly initiated oral weekly BP therapies, particularly for the patients started on generic alendronate.

Persistence with teriparatide in postmenopausal osteoporosis; impact of a patient education and follow-up program: the French experience

SUMMARY

This study evaluated the 18-month persistence with teriparatide in 5413 postmenopausal osteoporotic women who were enrolled in an education and follow-up program. Analysis showed that the persistence rate was 81.5% for women who follow the program, higher than for existing oral antiresorptive treatments.

INTRODUCTION

An education and follow-up program was developed after launch of teriparatide in France in September 2004, to help women to follow the treatment. The objective of this study was to evaluate the persistence with teriparatide in postmenopausal osteoporotic women following this program.

METHODS

Data about persistence are available for the period September 2004 to June 2007. Persistence is defined as the percentage of patients still on treatment at the end of the 18-month course, and it has been compared to the data provided by the French universal health insurance system.

RESULTS

Since the launch of teriparatide in France in September 2004, 5413 postmenopausal women (mean age 72.3 +/- 14.5 years) with osteoporosis and vertebral fractures (mean 3.9 +/- 2) have participated in the program. The persistence rate at 15 months was 81.5%, and our analysis suggested that a majority of patients completed the 18-month treatment course. The main reason for discontinuation was adverse events (46.7%). Data of the French Universal Health Insurance suggest that the persistence may be close to 0% for women who are not in the program.

CONCLUSIONS

Postmenopausal osteoporotic women treated by teriparatide and enrolled in an education and follow-up program have a high persistence rate.

Treatment of osteoporosis with annual iv zoledronic acid: effects on hip fracture

BACKGROUND

Several treatments for postmenopausal osteoporosis have been available in the past decade, but adherence to these treatments has been judged inadequate. The prevention of hip fracture by these medications is still modest.

METHODS

A literature search was performed for treatment with zoledronic acid for the prevention of hip fracture.

RESULTS

In the The Health Outcomes and Reduced Incidence with Zoledronic Acid Once Yearly (HORIZON) Pivotal Fracture Trial, involving 7765 postmenopausal women with low bone mineral density or with prevalent vertebral fracture, women taking zoledronic acid had a 41% relative risk reduction for hip fracture, at 3 years, compared to placebo. In the HORIZON Recurrent Fracture Trial, 2127 patients (76% were women) were randomized to receive either zoledronic acid or placebo after sustaining a first hip fracture. A reduction of 30% in the second hip fracture risk was observed, but it did not reach statistical significance. Zoledronic acid was generally safe in these trials, although a slightly increased rate of severe atrial fibrillations was observed in the HORIZON Prevention Fracture Trial, but not in the HORIZON Recurrent Fracture Trial.

CONCLUSION

Yearly zoledronic acid reduces the risk of hip fracture, both in postmenopausal osteoporotic women with and without prevalent vertebral fracture and in men and women with a recent first hip fracture.