Compliance with drug therapies for the treatment and prevention of osteoporosis

Osteoporosis medication profile preference: results from the PREFER-US study

Objective  To assess patient preferences for two osteoporosis medications.

Design  Women aged 50+ were surveyed via the Internet to assess preferences for two osteoporosis medication profiles. Drug A and Drug B, consistent with ibandronate and alendronate, respectively, differed by: time on market (recently vs. 10 years), dosing frequency (monthly vs. weekly), effectiveness (not proven vs. proven to reduce non‐spine or hip fracture after 3 years) and dosing procedure (60 vs. 30 min wait before eating/drinking). Each profile had the same out‐of‐pocket costs, side‐effects, potential for drug interaction and spine fracture efficacy. Patients force ranked and rated the importance of each attribute. Subgroup comparisons included diagnosed vs. at‐risk respondents and treated vs. untreated respondents.

Results  Among the 999 respondents, Drug B was preferred by 96%. Effectiveness was ranked as the most important determinant of preference (79% ranked it #1) compared with time on market (14%), dosing procedure (4%) and dosing frequency (3%). Effectiveness had the highest mean importance rating on a scale of 1 (extremely unimportant) to 7 (extremely important): mean (SD) = 6.1 (1.8), followed by time on market: 4.7 (1.7), dosing procedure: 4.6 (1.4) and dosing frequency: 4.5 (1.4). No significant differences in profile choice were found across study subgroups.

Conclusions  The drug profile showing reductions in non‐vertebral and hip fracture risk was chosen by almost all respondents. Drug effectiveness was the most important determinant of preference, while dosing frequency was the least important determinant. Incorporation of patient preferences in the medication decision‐making process could enhance patient compliance and clinical outcomes.

A model of the public health impact of improved treatment persistence in post-menopausal osteoporosis in France

BACKGROUND

Treatment of osteoporosis with bisphosphonates can lead to important reductions in fracture rates. The effectiveness of bisphosphonates is however limited by inadequate treatment persistence. The introduction of weekly administered forms has been associated with improved treatment persistence.

OBJECTIVES

This modelling study was designed to estimate the gain in persistence associated with a monthly treatment and the subsequent impact on fracture rates.

METHODS

Osteoporosis treatment rates and persistence rates were obtained from a French general practice registry for weekly and daily bisphosphonates and from a US managed care database for monthly bisphosphonates. Survival analyses were used to assess persistence. Fracture, hospitalisation and fracture rates were attributed based on data from clinical trials with bisphosphonates and epidemiological data.

RESULTS

Using a monthly treatment regimen, the reduction in the risk of vertebral and non-vertebral fractures with respect to untreated subjects was estimated to be 21.2% and 9.5% respectively. The reduction in risk of hospitalisation was estimated at 17.0% and the reduction of mortality at 18.1%. These reductions are around 60% higher as those estimated for daily bisphosphonate treatment and 25% higher than for weekly bisphosphonate treatment.

CONCLUSION

This modelling approach supports the notion that increased treatment persistence associated with use of monthly bisphosphonate treatment regimens may result in a significant impact on osteoporotic fracture rates and consequent hospitalisation and mortality rates.

Clinical application of biochemical markers of bone turnover

With the ageing population in most countries, disorders of bone and mineral metabolism are becoming increasingly relevant to every day clinical practice. Consequently, the interest in, and the need for effective measures to be used in the screening, diagnosis and follow-up of such pathologies have markedly grown. Together with clinical and imaging techniques, biochemical tests play an important role in the assessment and differential diagnosis of metabolic bone disease. In recent years, the isolation and characterisation of cellular and extracellular components of the skeletal matrix have resulted in the development of molecular markers that are considered to reflect either bone formation or bone resorption. These biochemical indices are non-invasive, comparatively inexpensive and, when applied and interpreted correctly, helpful tools in the diagnostic and therapeutic assessment of metabolic bone disease. This review provides an overview of the current evidence regarding the clinical use of biochemical markers of bone remodelling in bone disease, with an emphasis on osteoporosis.

A systematic review of persistence and compliance with bisphosphonates for osteoporosis

Fourteen reports utilizing data from de-identified administrative databases were reviewed. Studies contained at least one measure of patient persistence or compliance with bisphosphonates or bisphosphonates and other anti-osteoporosis medications. These studies confirm that women with osteoporosis have suboptimal persistence and compliance rates with bisphosphonate therapy.

INTRODUCTION

This review summarizes patient persistence and compliance with bisphosphonates for the treatment of osteoporosis.

METHODS

We conducted a MEDLINE search for the period from January 1998 to May 2006, using a detailed list of terms related to persistence and compliance with anti-osteoporosis medications. Studies were included if they contained at least one measure of persistence or compliance derived from de-identified administrative databases containing patient demographics and prescription information.

RESULTS

We reviewed 14 reports, which described 14 databases. The percentage of patients persisting with therapy for 1 year ranged from 17.9% to 78.0%. Compliance, assessed as mean medication possession ratio (MPR), ranged from 0.59 to 0.81. When comparing compliance with weekly and daily bisphosphonates, the mean MPR was consistently higher for weekly versus daily therapy (0.58 to 0.76 versus 0.46 to 0.64 for patients receiving weekly and daily bisphosphonate therapy respectively). Persistence was also improved in patients receiving weekly bisphosphonates, assessed by both length of persistence (194 to 269 days [weekly] and 134 to 208 days [daily]) and percentage of persistent patients at the end of the follow-up period (35.7% to 69.7% [weekly] and 26.1% to 55.7% [daily]).

CONCLUSION

Although patients using weekly bisphosphonate medication follow their prescribed dosing regimens better than those using daily therapy, overall compliance and persistence rates were suboptimal.

Elective oophorectomy in the gynecological patient: when is it desirable?

PURPOSE OF REVIEW

Oophorectomy is electively performed in approximately 300,000 US women per year who are having hysterectomy for benign disease.

RECENT FINDINGS

New studies have suggested that elective oophorectomy may not be advisable for the majority of women, as it may lead to a higher risk of death from cardiovascular disease and hip fracture, and may result in a higher incidence of dementia and Parkinson's disease. Women with known BRCA 1/2 germ-line mutations clearly benefit from oophorectomy after childbearing.

SUMMARY

Prophylactic oophorectomy should be undertaken with caution in the majority of women with an average risk of ovarian cancer who are having a hysterectomy for benign disease.

Ovarian conservation at the time of hysterectomy for benign disease

Approximately 78% of women between the ages of 45 and 64 years have prophylactic oophorectomy when hysterectomy is performed for benign disease to prevent the development of ovarian cancer. However, after menopause, the ovary continues to produce androstenedione and testosterone in significant amounts and these androgens are converted in fat, muscle, and skin into estrone. Evidence suggests that oophorectomy increases the subsequent risk of coronary heart disease (CHD) and osteoporosis and whereas 14,000 women die of ovarian cancer every year nearly 490,000 women die of heart disease and 48,000 women die within 1 year after hip fracture. PubMed and the Cochrane database were used to identify studies that examined the incidence of disease and mortality from 5 conditions that seem to be related to ovarian hormones: CHD, ovarian cancer, breast cancer, stroke and hip fracture, and also data for death from all other causes. The data were applied to a Markov decision analytic computer model to calculate risk estimates for mortality from these conditions until the age of 80. The model shows for a hypothetical cohort of 10,000 women undergoing hysterectomy and who chose oophorectomy (vs. ovarian conservation) between the ages of 50 and 54 [without estrogen therapy(ET)], that by the time they reach age 80, 47 fewer women will have died from ovarian cancer, but 838 more women will have died from CHD and 158 more will have died from hip fracture. Therefore, the decision to perform prophylactic oophorectomy should be approached with great caution for the majority of women who are at low risk of developing ovarian cancer.

Elective oophorectomy for benign gynecological disorders

OBJECTIVE

To review the risks and benefits of elective oophorectomy and to make a clinical recommendation for an appropriate age when benefits of this procedure outweigh the risks.

DESIGN

The risks and benefits of oophorectomy as detailed in published articles are reviewed with regard to quality-of-life issues and mortality outcomes in oophorectomized versus non-oophorectomized women from five diseases linked to ovarian hormones (coronary heart disease, ovarian cancer, breast cancer, stroke, and hip fracture).

RESULTS

Numerous reports link oophorectomy to higher rates of cardiovascular disease, osteoporosis, hip fractures, dementia, short-term memory impairment, decline in sexual function, decreased positive psychological well-being, adverse skin and body composition changes, and adverse ocular changes, as well as more severe hot flushes and urogenital atrophy. The potential benefits associated with oophorectomy include prevention of ovarian cancer, a decline in breast cancer risk, and a reduced risk of pelvic pain and subsequent ovarian surgery. In our study of long-term mortality after oophorectomy using Markov modeling, preservation of ovaries until women are at least aged 65 years was associated with higher survival rates. For women between ages 50 and 54 with hysterectomy and ovarian preservation, the probability of surviving to age 80 was 62% versus 54% if oophorectomy was performed. This 8% difference in survival is primarily due to fewer women dying from cardiovascular heart disease and/or hip fracture. This survival advantage far outweighs the 0.47% increased mortality rate from ovarian cancer prevented by oophorectomy. If surgery occurred between ages 55 and 59, the survival advantage was 4%. After age 64 there were no significant differences in survival rates. Prior literature supports our conclusion of a benefit over risk for ovarian conservation.

CONCLUSIONS

Elective oophorectomy is associated with short-and long-term health consequences that merit serious consideration. For women with an average risk of ovarian cancer, ovarian conservation until at least age 65 seems to benefit long-term survival.

Non-compliance: the Achilles' heel of anti-fracture efficacy

About 50% of patients fail to comply or persist with anti-osteoporosis treatment regimens within 1 year. Poor compliance is associated with higher fracture rates. Causes of poor compliance are unknown. As it is not possible to predict poor compliance, close monitoring of compliance is needed. Despite evidence supporting the anti-fracture efficacy of several pharmacological agents, approximately 50% of patients do not follow their prescribed treatment regimen and/or discontinue treatment within 1 year. Poor compliance is associated with higher fracture rates and increased morbidity, mortality and cost. However, as poor compliance, even to placebo, is associated with adverse outcomes, the higher morbidity appears to be only partly the result of lack of treatment: as yet, undefined characteristics place poor compliers at higher risk of morbidity and mortality. Only a small proportion (e.g., 6%) of the variability in compliance is explained by putative causal factors such as older age, co-morbidity or greater number of medications. Regimens with longer dosing intervals, such as weekly dosing, improve compliance, persistence and outcomes, but only modestly. As it is not possible to predict poor compliance, close monitoring of compliance should be an obligatory duty in clinical care. How this is best achieved has yet to be established, but poor persistence occurs as early as 3 months of starting treatment, indicating the need for early monitoring.

Developments of the incidence of osteoporosis in The Netherlands: a PHARMO study

PURPOSE

To assess recent and to predict future time trends in the incidence of osteoporosis using routine databases in The Netherlands in the period 1993-2015 and to compare estimations based on hip fractures versus a proxy based on pharmacy and hospitalisation data.

METHODS

The incidence of hip fractures was estimated over the period 1986-2002 using information from the Dutch Medical Registry, covering more than 99% of all Dutch hospitalisations. Additionally, a proxy (hospitalisation for osteoporosis or osteoporotic fractures, treatment with glucocorticosteroids or treatment with anti-osteoporosis drugs) was constructed in order to identify osteoporotic patients in the PHARMO database. Age and gender specific incidences of hip fractures and osteoporosis were calculated and extrapolated to The Netherlands. Results of both studies were extrapolated till 2015 using a power function.

RESULTS

The incidence of hip fractures decreased slightly (270 per 100,000 in 1993, 260 per 100,000 in 2002). The incidence of osteoporosis using the constructed proxy decreased from 870 per 100,000 in 1993 to 700 per 100,000 in 2002. The incidence of hip fractures and osteoporosis remained fairly constant when modelled till 2015. Both studies showed the same time trends.

CONCLUSION

Both the estimations based on the hospitalisations for hip fracture and on our proxy for osteoporosis showed that the increase in the incidence of osteoporosis as observed in the 1990s is levelling off. Due to ageing of the population the absolute number of hip fractures will however increase. Our definition of osteoporosis resulted in a higher estimation of the incidence of osteoporosis and may be used in future studies to follow developments in osteoporosis prevalence and incidence.

Spanish post-menopausal women's viewpoints on hormone therapy

OBJECTIVE

The purpose of this study was to identify women's socio-demographic and climacteric factors, as well as other variables related to health care, associated with the prescription of the treatment during menopause and to investigate the prevalence of certain conditioning factors in early discontinuation in women aged 40-65 years in a population of post-menopausal women in Spain.

STUDY DESIGN

Cross-sectional survey.

SETTING

Four of the most inhabited cities in Spain (Madrid, Barcelona, Seville and Valencia).

POPULATION

A total of 270 symptomatic post-menopausal women.

METHODS

A personal interview with a semi-structured questionnaire specifically designed to collect information on treatments for climacteric-related complaints.

MAIN OUTCOME MEASURES

The reasons for HRT, the evaluation of alternative therapies, the reasons for choosing one therapy or another and reasons for discontinuation.

RESULTS

Of all the subjects included, 180 were still taking any type of treatment and 90 were former HRT users or had never used HRT. Among the latter, 43% of women expressed fear of the side effects and 38% gave the risk of breast cancer as the main reason for not using HRT. Of them, 58% receive phytoestrogens. Media and negative data from medical journals influenced this attitude in 67% of the women. On the other hand, only 9.4% of HRT users were reluctant to receive the therapy and the main reasons for maintaining HRT were its efficacy against climacteric symptoms, medical prescription and life quality.

CONCLUSIONS

Side effects and fear of cancer were the most common reasons for not using HRT; and medical prescription, symptomatic improvement and quality of life were the main reasons for using it. Negative data from journals have an important effect on women's attitudes to HRT.

Effect of monitoring bone turnover markers on persistence with risedronate treatment of postmenopausal osteoporosis

CONTEXT

Persistence with osteoporosis treatment is poor but is important for maximum benefit.

OBJECTIVE

The objective of the study was to assess the impact of physician reinforcement using bone turnover markers (BTMs) on persistence with risedronate treatment.

DESIGN AND SETTING

This was a 1-yr multinational prospective, open-label, blinded study in 171 osteoporosis centers in 21 countries.

PATIENTS

A total of 2382 postmenopausal women (65-80 yr old) with spine/hip T-score -2.5 or less or T-score -1.0 or less with a low-trauma fracture.

INTERVENTION

Intervention included calcium 500 mg/d, vitamin D 400 IU/d, and risedronate 5 mg/d for 1 yr. Centers were randomized to reinforcement (RE+) or no reinforcement (RE-). At 13 and 25 wk, reinforcement based on urinary N-telopeptide of type I collagen change from baseline was provided to the RE+ patients using the following response categories: good (>30% decrease), stable (-30% to +30% change), or poor (>30% increase).

MAIN OUTCOME MEASURES

Persistence assessed with electronic drug monitors was measured.

RESULTS

In the overall efficacy population (n=2302), persistence was unexpectedly high and was similar for both groups (RE-, 77%; RE+, 80%; P=0.160). A significant relationship between the type of message and persistence was observed (P=0.017). Compared with RE-, intervention based on a good BTM response was associated with a significant improvement in persistence [hazard ratio (HR) 0.71; 95% confidence interval (CI) 0.53-0.95]. Persistence was unchanged (HR 1.02; 95% CI 0.74-1.40) or lower (HR 2.22; 95% CI 1.27-3.89) when reinforcement was based on a stable or poor BTM response, respectively. Reinforcement was associated with a lower incidence of new radiologically determined vertebral fractures (odds ratio 0.4; 95% CI, 0.2-1.0).

CONCLUSIONS

Reinforcement using BTMs influences persistence with treatment in postmenopausal women with osteoporosis, depending on the BTM response observed.

Compliance with osteoporosis drug therapy and risk of fracture

INTRODUCTION

Patient compliance with osteoporosis drug therapy is often poor in clinical practice and may be associated with higher risk of fracture.

METHODS

A nested case-control study was undertaken using a US health insurance claims database. The source population included all women aged >or=45 years who began drug therapy for osteoporosis. Cases consisted of those who experienced an osteoporosis-related fracture; they were matched to controls without osteoporosis-related fracture. Compliance with osteoporosis drug treatment was assessed in terms of the number of therapy-days received and medication possession ratio (MPR). Conditional logistic regression was employed to examine the relationship between compliance and fracture risk.

RESULTS

A total of 453 women with osteoporosis-related fracture were identified and matched to 2,160 controls. Fracture risk was significantly lower for patients with >180 days of therapy [181-360 days: odds ratio (OR) = 0.70, 95% CI = 0.49-0.99; >360 days: OR = 0.65, 95% CI = 0.43-0.99) versus those with <or=30 days. Risk was also lower for patients with MPR >or=90% (OR = 0.70, 95% CI = 0.52-0.93) versus those with MPR <30%. Fracture risk decreased as compliance increased (p(trend) < 0.05).

CONCLUSION

Among women initiating drug therapy for osteoporosis, better compliance is associated with reduced risk of fracture.

Impact of increased overweight on the projected prevalence of osteoporosis in older women

INTRODUCTION

Overweight is increasing worldwide, but particularly in the United States of America. Higher body weight is associated with higher bone density, so our goal was to estimate whether the higher prevalence of overweight is likely to reduce osteoporosis among older women.

METHODS

We calculated the prevalence of osteoporosis by weight status in older women using data from the third National Health and Nutrition Examination Survey (NHANES III, 1988-94). We defined overweight as a body mass index (BMI) >or=25 and osteoporosis as a femur neck bone mineral density (BMD) value 2.5 standard deviations or more below the mean of that of young women. To estimate the expected prevalence of osteoporosis, we applied the prevalence of osteoporosis by weight status from NHANES III to the corresponding weight status prevalence from NHANES 1999-2002.

RESULTS

Of older women in NHANES 1999-2002, 68% were overweight compared to 62% in NHANES III. Overweight status was significantly related to osteoporosis prevalence (P < 0.001). However, the expected prevalence of osteoporosis in NHANES 1999-2002 was only slightly lower than that seen in NHANES III (16.8% vs 18.1%, respectively).

CONCLUSIONS

The increasing prevalence of overweight among older US women appears unlikely to be accompanied by a significant reduction in osteoporosis.

An Evaluation of patients' preferences for osteoporosis medications and their attributes: The PREFER-international study

BACKGROUND

Patients' preferences for medications may be important in determining their compliance with therapy, particularly in the case of an asymptomatic chronic disease such as osteoporosis. Although preferences for certain attributes of osteoporosis medications, including dosing frequency and tolerability, can be evaluated in short-term clinical trials, years of use may be necessary for differences in effectiveness in reducing fracture risk to emerge.

OBJECTIVES

The primary aim of this study was to evaluate the relative importance of various attributes in determining patients' preferences for osteoporosis medications. Its secondary aim was to investigate patients' preferences for either of 2 hypothetical osteoporosis medications with different profiles.

METHODS

The Preference for Effective Regimens (PREFER)-International study was a cross-sectional survey of postmenopausal women with osteoporosis in France, Germany, Mexico, Spain, and the United Kingdom. Participants were recruited by their physicians in the 4 European countries and were identified by trained interviewers going door to door in Mexico. Participants were administered a questionnaire in which they were asked to rate and rank the importance of 7 medication attributes in determining their preferences for prescription osteoporosis medications. The attributes were side effects, out-of-pocket costs, effectiveness in improving bone health and preventing fractures, dosing frequency, formulation, administration procedure, and length of time on the market. They were also asked to indicate their preference for 2 hypothetical osteoporosis medications whose profiles differed in terms of efficacy (medication A reduced the risk of spine and hip fracture; medication B reduced spine fracture only), time on the market (10 years vs recently introduced), dosing frequency (weekly vs monthly), and dosing procedure (30- vs 60-minute wait after dosing).

RESULTS

Of 3000 patients interviewed, 1500 were receiving prescription treatment for osteoporosis. Across the rankings and ratings, effectiveness in reducing the risk of fracture emerged as the most important factor in determining patients' preferences for prescription osteoporosis medications, followed by side effects. Out-of-pocket costs, dosing frequency, formulation, time on the market, and dosing procedure were less important considerations among respondents from most countries. The majority (78%) of patients indicated a preference for medication A over medication B.

CONCLUSION

Effectiveness in reducing fracture risk was cited as the primary reason for patients' preference for prescription osteoporosis medications among postmenopausal women with osteoporosis from 4 European countries and Mexico.

The effect of dosing frequency on compliance and persistence with bisphosphonate therapy in postmenopausal women: a comparison of studies in the United States, the United Kingdom, and France

OBJECTIVES

The aim of this study was to determine the effect of dose frequency on compliance and persistence with bisphosphonate therapy in postmenopausal women and to compare findings from 3 different health care systems.

METHODS

Three independently performed retrospective cohort analyses were performed using observational data sources. In the United States, bisphosphonate-naive postmenopausal women were identified from a database providing information on health plan prescription drug claims; in the United Kingdom and France, bisphosphonate-naive postmenopausal women were identified from a database of medical records supplied by general practice physicians. The women were grouped into 2 cohorts: those who were initiated on a weekly regimen of alendronate 70 mg or risedronate 35 mg and those initiated on a daily regimen of alendronate 5 or 10 mg or risedronate 5 mg. Compliance was measured in terms of the medication possession ratio (MPR), which was defined as the proportion of days in the 12-month follow-up period for which patients were covered by prescriptions for bisphosphonates. Persistence was measured as the number of days from the date of the index prescription to the last day of prescription coverage within the followup period. Women were classified as nonpersistent if the gap between prescriptions was > 30 days.

RESULTS

The study included 2741 postmenopausal women with osteoporosis from the United States, 7567 from the United Kingdom, and 5332 from France. The mean (SD) age of the women was 73.0, 71.7, and 69.7 years in the 3 countries, respectively. The overall MPR was 61% in the United States, 74% in the United Kingdom, and 58% in France. In all 3 countries, women on a weekly regimen had a significantly greater MPR than women on a daily regimen (69% vs 58%, respectively, in the United States; 76% vs 64% in the United Kingdom; and 59% vs 53% in France; all, P < 0.001). Women on a weekly regimen of bisphosphonates persisted with treatment significantly longer than women on a daily regimen (227 vs 185 days, respectively, in the United States; 249 vs 208 in the United Kingdom; and 179 vs 155 in France; all, P < 0.001). A significantly greater proportion of the women on a weekly regimen persisted with treatment for 12 months compared with those on a daily regimen (44% vs 32%, respectively, in the United States; 52% vs 40% in the United Kingdom; and 51% vs 44% in France; all, P < 0.001).

CONCLUSIONS

In all 3 countries, postmenopausal women prescribed a weekly regimen of bisphosphonates had significantly greater rates of compliance than women prescribed a daily regimen, and they persisted longer with treatment. However, compliance and persistence rates were suboptimal for both regimens.

Effectiveness of bisphosphonates on nonvertebral and hip fractures in the first year of therapy: the risedronate and alendronate (REAL) cohort study

INTRODUCTION

Randomized clinical trials have shown that risedronate and alendronate reduce fractures among women with osteoporosis. The aim of this observational study was to observe, in clinical practice, the incidence of hip and nonvertebral fractures among women in the year following initiation of once-a-week dosing of either risedronate or alendronate.

METHODS

Using records of health service utilization from July 2002 through September 2004, we created two cohorts: women (ages 65 and over) receiving risedronate (n = 12,215) or alendronate (n = 21,615). Cox proportional hazard modeling was used to compare the annual incidence of nonvertebral fractures and of hip fractures between cohorts, adjusting for potential differences in risk factors for fractures.

RESULTS

There were 507 nonvertebral fractures and 109 hip fractures. Through one year of therapy, the incidence of nonvertebral fractures in the risedronate cohort (2.0%) was 18% lower (95% CI 2% - 32%) than in the alendronate cohort (2.3%). The incidence of hip fractures in the risedronate cohort (0.4%) was 43% lower (95% CI 13% - 63%) than in the alendronate cohort (0.6%). These results were consistent across a number of sensitivity analyses.

CONCLUSION

Patients receiving risedronate have lower rates of hip and nonvertebral fractures during their first year of therapy than patients receiving alendronate.

Patient Adherence to Osteoporosis Medications

Adherence to osteoporosis medications is relatively poor. Approximately 20-30% of patients taking daily or weekly treatments may suspend their treatment within 6 to 12 months of initiating therapy. Patients with poor adherence increase their risk of osteoporotic fractures and hospitalisation. The majority of patients who discontinue therapy appear to do so because of drug-induced adverse effects. Fear of adverse effects or other health risks is another commonly cited reason for discontinuing therapy. Factors associated with medication adherence include fractures, regular exercise, female sex, fewer non-osteoporosis medications and co-morbidities, early menopause, willingness to take medications, awareness of osteoporosis status based on a diagnostic test, anti-inflammatory therapy and corticosteroid therapy. Factors associated with non-adherence include adverse effects, pain and being unsure about bone mineral density (BMD) test results. Bisphosphonates, a common class of drugs for treating osteoporosis, have specific administration requirements (e.g. fasting, remaining upright and not ingesting other medications concomitantly). Patient surveys indicate that 12-18% of patients report non-compliance with at least one administration rule. Strategies to increase adherence include reducing administration frequency to weekly or monthly, monitoring patients with bone markers and BMD testing, providing adequate instructions, practitioner feedback and support, and educational materials and sessions. Future studies are needed regarding strategies to increase adherence to osteoporosis medications.

Using computers to identify non-compliant people at increased risk of osteoporotic fractures in general practice: a cross-sectional study

BACKGROUND

National guidelines recommend bisphosphonates for secondary prevention of osteoporotic fractures; however, poor compliance may result in sub-optimal prevention.

OBJECTIVE

This study reports the feasibility of using GP electronic records to identify poorly compliant post-menopausal women who may be at increased risk of fragility fractures.

DESIGN

Cross-sectional study of general practice computer records.

SUBJECTS

Women over 45 years, registered in 29 practices across England with a total population of approximately 200,000.

METHODS

MIQUEST (Morbidity Information Query and Export Syntax) a data extraction application was used to extract prescription, diagnostic data and probable fragility fractures (hip, vertebral, wrist). All women >45 years who received a first prescription for a weekly bisphosphonate (alendronate or risedronate) at least a year before data extraction were identified. Each record was examined to determine the number of days of prescribed treatment.

RESULTS

Of 97992 registered women, 44% (42734) were >45 years. Prevalence of likely fragility fractures in women over 45 was 5.1% (2195/42734). 3.0% (1286/42734, mean age 72 years) received a prescription for a bisphosphonate in the 360 day period prior to data extraction with a median duration of treatment of 267 days. 45% (584/1286) received prescriptions covering >288/360 days (Medicine Possession Ratio >80%); 13% (161/1286) collected prescriptions covering >360 days. In those prescribed bisphosphonates, 23% (294/1286) had a likely fragility fracture.

CONCLUSIONS

Women >45 years with probable fragility fractures are more likely to be prescribed bisphosphonates, though less than half will be actually taking them as prescribed. GPs should use computer technology to identify poorly compliant patients who are unnecessarily at risk of fracture.

Improving the quality of clinical care for patients with osteoporosis

Osteoporosis, leading to hip fractures and other fragility fractures, is prevalent in countries with a high life expectancy. Fractures have a high associated societal cost and disease burden. As a result, many countries have established screening guidelines for osteoporosis, especially targeting those at a higher risk. However, primary- and secondary-fracture prevention is currently suboptimal despite existence of effective medications. In addition, adherence to therapy is low. This special report outlines some of these challenges and evaluates different techniques for improving the quality of clinical care for patients with osteoporosis.

Assessing the content and quality of information on the treatment of postmenopausal osteoporosis on the World Wide Web

OBJECTIVE

To evaluate the content and quality of currently available Internet-based information on the treatment of postmenopausal osteoporosis.

DESIGN

A sample was obtained comprising the 75 top sites retrieved with the Google search engine using 'treatment of postmenopausal osteoporosis' and then evaluated according to predefined general and specific criteria, content type, language and quality. Using a systematic scoring tool, each site was assessed for factual information provided and site quality.

RESULTS

The sites studied were heterogeneous in content and quality. The most frequent type of website corresponded to non-profit organizations (n = 40), followed by commercial sites (n = 19), professional sites (n = 8) and government sites (n = 8). There were no significant differences in the popularity index, medical content score or quality score among the four groups of sites. Twelve websites were papers published in peer-reviewed medical journals. Few sites provided comprehensive medical and complete information on the treatment of postmenopausal osteoporosis oriented towards consumers. The consumer-oriented webpage with the most balanced and complete information was that of the National Osteoporosis Foundation which, at the same time, had the highest popularity index of all the resources studied.

CONCLUSION

The content and quality of websites concerning the treatment of postmenopausal osteoporosis are highly varied and sometimes biased. The most frequent high-quality information corresponds to peer-reviewed medical journals. It is necessary to increase the number of resources, with rigorous language that is understandable for consumers, in relation to the treatment of postmenopausal osteoporosis.

Medication persistence with weekly versus daily doses of orally administered bisphosphonates

OBJECTIVE

To compare medication persistence among patients receiving daily orally administered bisphosphonates with persistence among patients receiving weekly orally administered bisphosphonates to ascertain whether less frequent dosing is associated with better long-term treatment persistence.

METHODS

A large, longitudinal cohort of female patients (N = 211,319) receiving prescriptions for alendronate or risedronate from approximately 14,000 US retail pharmacies was assessed. Medication persistence was defined as the percentage of patients who continued to take bisphosphonate therapy during each month (that is, having at least 1 day of medication supply in that month) for a 1-year observation period.

RESULTS

The inconvenience and complexity of required dosing procedures with oral bisphosphonate therapy for the prevention and treatment of osteoporosis are thought to be major factors that hinder medication persistence, and poor persistence is associated with suboptimal health-care outcomes. In this study, the percentage of patients continuing to take bisphosphonate therapy steadily declined with both daily and weekly oral treatment regimens during the course of the 12-month observation period. Consistently, however, medication persistence was higher among patients receiving the weekly rather than the daily regimen. Only 56.7% of patients receiving the weekly regimen and only 39.0% of patients receiving the daily regimen continued to take bisphosphonate therapy at month 12 of the study period (P<0.0001).

CONCLUSION

This study demonstrates that weekly dosing of orally administered bisphosphonates is associated with higher medication persistence than is daily dosing. Nevertheless, more than 40% of patients did not persist with weekly bisphosphonate therapy for at least 12 months. Thus, medication persistence was inadequate even with use of the weekly regimen. Additional research is needed to determine whether persistence can be further improved by extending the dosing interval beyond once weekly.

Adherence to Medications for the Treatment of Osteoporosis

Although there is a wide variety of osteoporosis medications with varying dosing intervals, adherence to therapies for postmenopausal- or glucocorticoid-induced osteoporosis remains poor. It is associated with long-term consequences, such as increased osteoporotic fractures, including nonvertebral hip fractures. There is a lack of understanding about why patients are not staying on therapy. Potential solutions include newer medications with extended dosing intervals, monitoring, and an open physician-patient relationship.

Treating osteoporosis with bisphosphonates and addressing adherence: a review of oral ibandronate

Osteoporosis is a common, chronic condition, affecting approximately half of all postmenopausal Caucasian women in the US. Vertebral fractures occur as a result of osteoporosis and lead to increased hospitalisation and mortality, and adversely affect patient quality of life. The burden of osteoporosis on healthcare systems is expected to rise as the elderly population continues to grow. Yet there are many medications for preventing and treating osteoporosis. Oral bisphosphonates are first-line treatment for osteoporosis, with demonstrated efficacy in increasing bone mineral density and reducing bone turnover, which reduces the incidence of fractures. However, adherence to medication is suboptimal, with approximately 40% of patients discontinuing treatment within 6 months. Recent reports have suggested simplifying the dosage regimen as a strategy to help address this issue. Ibandronate is a potent, nitrogen-containing bisphosphonate which is administered once-monthly. Preclinical studies initially revealed the feasibility of extending the between-dose interval. Subsequent clinical studies have provided further evidence of the positive effects of extended-interval ibandronate administration in reducing the risk of vertebral fractures through increasing bone mineral density and reducing bone turnover without compromising bone quality. These studies have also demonstrated that ibandronate has a safety profile similar to placebo. Ibandronate has recently been approved for use in the US to treat postmenopausal osteoporosis. This review summarises the efficacy and safety of once-monthly oral ibandronate and discusses the implications of such a treatment in primary care in the US.

RANK ligand inhibition with denosumab for the management of osteoporosis

Receptor activator of nuclear factor-kappaB ligand (RANKL) is a cytokine member of the tumour necrosis factor family that is the principal final mediator of osteoclastic bone resorption. It plays a major role in the pathogenesis of postmenopausal osteoporosis, as well bone loss associated with rheumatoid arthritis, metastatic cancer, multiple myeloma, aromatase inhibitor therapy and androgen deprivation therapy. Denosumab (AMG 162) is an investigational fully human monoclonal antibody with a high affinity and specificity for RANKL. By inhibiting the action of RANKL, denosumab reduces the differentiation, activity and survival of osteoclasts, thereby slowing the rate of bone resorption. Denosumab has been shown to increase bone mineral density (BMD) and reduce bone turnover in postmenopausal women with low BMD. Denosumab is a potential treatment for osteoporosis and other skeletal disorders.

Alendronate sodium in the management of osteoporosis

Alendronate is one of the best and most extensively studied bisphosphonates in the treatment of osteoporosis. This review considers in detail the major pivotal study, the fracture intervention trial (FIT), upon which the use of alendronate is based and which was a landmark study in terms of design, size and clinical impact. The role of alendronate has subsequently been underscored by a range of studies extending the clinical indications for its use and consolidating the effect on reducing both vertebral and non-vertebral fracture risk. Although the emphasis of these studies has predominantly been on the management of postmenopausal osteoporosis, data is also available in primary prevention, men, and glucocorticoids-induced osteoporosis. Direct comparison between the different drugs used to treat osteoporosis with fracture end points are needed for patients and doctors to make informed choices, but the size of such studies are prohibitive. Clinical trials using surrogate markers such as bone mineral density and biochemical markers of bone turnover have been performed which provide some helpful information but the limitations of this approach need to be recognized.

Clinical guidelines for improving compliance with hormone therapy in Latin American women during the menopausal transition and thereafter

OBJECTIVE

To provide uniform, objective guidance for physicians and other health care workers in Latin America to enhance compliance with hormone therapy (HT), and to provide a tool for continued medical education and a source for answering clinical questions.

METHOD

Literature search using MEDLINE; identification of key relevant publications by a five-member expert committee; creation and validation of a 60-item questionnaire used to survey the opinion of 72 physicians participating in a Latin American symposium, "The Faces of Menopause".

RESULTS

On the basis of the validated responses, major points were identified to enhance compliance with HT with specific reference to Latin America, and two algorithms were created to provide practical guidance.

CONCLUSION

The present guidelines will facilitate optimal compliance with therapy in Latin American postmenopausal women who opt for HT and for whom HT is indicated.

Adherence to bisphosphonate therapy and fracture rates in osteoporotic women: relationship to vertebral and nonvertebral fractures from 2 US claims databases

OBJECTIVE

To characterize the relationships between adherence (complance and persistence) to bisphosphonate therapy and risk of specific fracture types in postmenopausal women.

PATIENTS AND METHODS

Data were collected from 45 employers and 100 health plans in the continental United States from 2 claims databases during a 5-year period (January 1, 1999, through December 31, 2003). Claims from patients receiving a bisphosphonate prescription (alendronate or risedronate) were evaluated for 6 months before the Index prescription and during 24 months of follow-up to determine total, vertebral, and nonvertebral osteoporotic fractures, persistence (no gap in refills for >30 days during 24 months), and refill compliance (medication possession ratio > or = 0.80).

RESULTS

The eligible cohort included 35,537 women (age, > or = 45 years) who received a bisphosphonate prescription. A subgroup with a specified diagnosis of postmenopausal osteoporosis was also evaluated. Forty-three percent were refill compliant, and 20% persisted with bisphosphonate therapy during the 24-month study period. Total, vertebral, nonvertebral, and hip fractures were significantly lower in refill-compliant and persistent patients, with relative risk reductions of 20% to 45%. The relationship between adherence and fracture risk remained significant after adjustment for baseline age, concomitant medications, and fracture history. There was a progressive relationship between refill compliance and fracture risk reduction, commencing at refill compliance rates of approximately 50% and becoming more pronounced at compliance rates of 75% and higher.

CONCLUSIONS

Adherence to bisphosphonate therapy was associated with significantly fewer fractures at 24 months. Increasing refill compliance levels were associated with progressively lower fracture rates. These findings suggest that incremental changes in medication-taking habits could improve clinical outcomes of osteoporosis treatment.

Psychometric evaluation of the Osteoporosis Patient Treatment Satisfaction Questionnaire (OPSAT-Q), a novel measure to assess satisfaction with bisphosphonate treatment in postmenopausal women

Background

The Osteoporosis Patient Satisfaction Questionnaire (OPSAT-Q) is a new measure of patient satisfaction with bisphosphonate treatment for osteoporosis. The objective of this study was to evaluate the psychometric characteristics of the OPSAT-Q.

Methods

The OPSAT-Q contains 16 items in four subscales: Convenience, Confidence with Daily Activities, Side Effects, and Overall Satisfaction. All four subscale scores and an overall composite satisfaction score (CSS) can be computed. The OPSAT-Q, Osteoporosis Targeted Quality of Life (OPTQoL), and sociodemographic/clinical questionnaires, including 3 global items on convenience, functioning and side effects, were self-administered to women with osteoporosis or osteopenia recruited from four US clinics. Analyses included item and scale performance, internal consistency reliability, reproducibility, and construct validity. Reproducibility was measured using the intraclass correlation coefficient (ICC) via a follow-up questionnaire completed by participants 2 weeks post baseline.

Results

104 women with a mean age of 65.1 years participated. The majority were Caucasian (64.4%), living with someone (74%), and not currently employed (58.7%). 73% had osteoporosis and 27% had osteopenia. 80% were taking weekly bisphosphonates and 18% were taking daily medication (2% missing data). On a scale of 0–100, individual patient subscale scores ranged from 17 to 100 and CSS scores ranged from 44 to 100. All scores showed acceptable internal consistency reliability (Cronbach's alpha > 0.70) (range 0.72 to 0.89). Reproducibility ranged from 0.62 (Daily Activities) to 0.79 (Side Effects) for the subscales; reproducibility for the CSS was 0.81. Significant correlations were found between the OPSAT-Q subscales and conceptually similar global measures (p < 0.001).

Conclusion

The findings from this study confirm the validity and reliability of the OPSAT-Q and support the proposed composition of four subscales and a composite score. They also support the use of the OPSAT-Q to examine the impact of bisphosphonate dosing frequency on patient satisfaction.

Determinants of persistence with bisphosphonates: a study in women with postmenopausal osteoporosis

BACKGROUND

Although bisphosphonates are useful in the management of osteoporosis, patients often discontinue treatment.

OBJECTIVES

The aims of this study were to investigate persistence with bisphosphonates, and to assess whether the dose interval influenced persistence, among women with postmenopausal osteoporosis.

METHODS

Data were obtained from the PHARMO Record Linkage System, which includes, among other databases, drug-dispensing records from community pharmacies linked to hospital discharge records of > 1 million subjects in defined areas in The Netherlands. Women who were new users of alendronate (daily or weekly), etidronate (daily), or risedronate (daily) during the period from January 2000 through September 2003 were eligible for inclusion in the study if they were aged > or = 55 years or had been hospitalized for a menopausal disorder. One-year rates of persistence with treatment (defined as the percentage of patients who used the drug for > or = 365 days without failure to continue renewals) were determined by using episodes of bisphosphonate treatment. The association between persistence and dose intervals, type of bisphosphonate, and other determinants (including age, occurrence of gastrointestinal adverse events as measured by use of concomitant medications [eg, antacids, proton pump inhibitors, histamine2 (H2)-receptor antagonists, misoprostol, laxatives, antidiarrheals, bowel motility enhancers] and fractures) was assessed. To study whether persistence with bisphosphonates was associated with the former use of other antiosteoporosis medication or the presence of drug-induced osteoporosis, the use of hormone replacement therapy, raloxifene, and systemic corticosteroids in the 6 months before the index date were included as determinants.

RESULTS

The study sample included 2124 women who were new users of bisphosphonates. The mean (SD) age of the study population was 71.6 (8.7) years. After 1 year, 51.9% of weekly alendronate users and 30.1% to 42.2% of daily bisphosphonate users were persistent. In the multivariate analysis (which included age, concomitant medication, and fractures), patients using alendronate weekly were significantly more likely to persist than those using alendronate daily (relative risk [RR], 1.56 [95% CI, 1.32-1.85]). The likelihood of persistence was similar among those who used the daily regimens of risedronate, etidronate, and alendronate. The occurrence of gastrointestinal adverse events was associated with decreased persistence with bisphosphonates (H2)-receptor antagonists: RR, 0.71 [95% CI, 0.53-0.94]; bowel motility enhancers: RR, 0.78 [95% CI, 0.65-0.94]).

CONCLUSIONS

In this study, dose interval and the occurrence of gastrointestinal adverse events were independent determinants of persistence with bisphosphonate therapy. Although the likelihood of persistence with bisphosphonate use was significantly higher among those who used a less frequently administered regimen, persistence rates were still suboptimal.

Adherence and Persistence Associated with the Pharmacologic Treatment of Osteoporosis in a Managed Care Setting

BACKGROUND

The effectiveness of chronic therapies can be compromised by poor adherence and persistence.

MATERIALS AND METHODS

Investigators identified a continuously benefit-eligible cohort of women from a large, geographically diverse, national managed care plan who were newly diagnosed and treated for osteoporosis with alendronate, risedronate, or raloxifene. Drug utilization parameters were evaluated over a 12-month follow-up period for the study population. Adherence was assessed using a medication possession ratio calculated as total days of therapy for medication dispensed/365 days of study follow-up. Persistence was defined as continuous therapy on the same drug for each month over the entire study period. Adherence and persistence were also evaluated for all three study agents in women > or = 65 years of age.

RESULTS

In the study cohort (N = 10,566), 12-month adherence/ persistence rates were alendronate 61%/21%, risedronate 58%/19%, and raloxifene 54%/16%. Rates in women > or = 65 years were similar to those in the entire study cohort. Weekly bisphosphonate users had slightly higher 12-month adherence (63% versus 54%, P < 0.05) and persistence (22% versus 19%, P = NS) rates than did daily users, independent of agent.

CONCLUSION

Chronic oral-dosed osteoporosis therapies are associated with poor adherence and persistence, regardless of age or dosing regimen. Drug therapies and patient management approaches associated with improved adherence and persistence could improve the likelihood of achieving the therapeutic benefits observed in rigorously controlled clinical trials.

Addressing and meeting the needs of osteoporotic patients with strontium ranelate: a review

Patients with osteoporosis need a safe and effective treatment that reduces the risk of vertebral and non-vertebral fractures, leading to clinical benefits such as reduced back pain and height loss. Strontium ranelate corrects bone turnover, producing a more physiological state. Double-blind, placebo-controlled studies in postmenopausal osteoporosis show it to be effective in reducing vertebral and non-vertebral fracture risks. Treatment efficacy has been documented across a wide range of patient profiles, and appears to be independent of all the major determinants of fracture risk, including the severity of the disease at baseline, the number of prevalent fractures, and the age of the patient. This antifracture efficacy translates into clinical benefits, such as a 20% reduction in the rate of height loss and a 29% increase in the number of patients free of back pain. The effect of treatment with strontium ranelate on well-being has been assessed using the Quality-of-Life Questionnaire in Osteoporosis, which is a supplement to the 36-question Short-Form Health Survey. Treatment with strontium ranelate had a significant beneficial effect on the emotional, physical, and global Quality-of-Life Questionnaire in Osteoporosis scores compared with placebo. The rates of compliance with treatment were over 80% in phase III studies, reflecting the tolerability and safety profile and the ease of administration of this agent. Together with the antifracture data, the clinical benefits and quality of life data endorse the treatment of postmenopausal osteoporosis with strontium ranelate.

Assessment of compliance with osteoporosis treatment and its consequences in a managed care population

OBJECTIVE

To evaluate non-compliance with osteoporosis medications as well as its implications for health and economic outcomes in actual practice.

STUDY DESIGN

Data on demographics, prescription drug dispensing, physician services and hospitalizations were obtained from a US managed care database for women with osteoporosis who were dispensed an osteoporosis medication between 1997 and 2002.

METHODS

Each subject's pattern of osteoporosis medication use was reconstructed using dispensing records. Subjects were considered compliant over a given period if their medication possession ratio (MPR) was >or=80% and gradients of compliance (<50% poor, 50-80% medium, 80-90% good, >90% excellent) were also examined. Using proportional hazards, the association between compliance over time and fracture rates was examined; Poisson regression was used for hospitalization and log-linear regression for medical costs.

RESULTS

38,120 women with osteoporosis were identified with a mean age of 66 years and an average follow-up of 1.7 years. Three quarters of them had an MPR below 80% when their entire follow-up was considered. Low compliance was associated with a 17% (95% CI 9-25%) increase in the fracture rate, adjusting for other known risk factors. Controlling for the specific drug regimen did not alter the association. Low compliance was also associated with a 37% (95% CI 32-43%) increase in the risk of all-cause hospitalization; and average monthly costs for all medical services combined were higher: 600 US dollars vs. 340 US dollars (P < 0.0001). Similar associations were observed when using the gradients of compliance.

CONCLUSIONS

The desired goal of keeping patients with osteoporosis on chronic treatment is not being achieved adequately in actual practice and the potential social and economic implications of this behavior are substantial. Until compliance is improved, society will continue to fail in meeting an important public health goal.

Management of osteoporosis in postmenopausal women

OBJECTIVE

To update the evidence-based position statement published by The North American Menopause Society (NAMS) in 2002 regarding the management of osteoporosis in postmenopausal women.

DESIGN

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 were enlisted to review the 2002 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, whose prevalence is especially high among elderly 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, a selective estrogen-receptor modulator, parathyroid hormone, estrogens, and calcitonin.

CONCLUSIONS

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

Once-monthly Ibandronate for postmenopausal Osteoporosis: Review of a new dosing regimen

BACKGROUND

Ibandronate, a nitrogen-containing bisphosphonate, was approved by the US Food and Drug Administration (FDA) in May 2003 as a daily oral regimen for the treatment and prevention of post-menopausal osteoporosis. In March 2005, the FDA approved once-monthly dosing with ibandronate for the same indications.

OBJECTIVE

The purpose of this article was to review the efficacy and tolerability of ibandronate 150 mg once monthly in the treatment and prevention of post-menopausal osteoporosis.

METHODS

A search of MEDLINE (1966-September 2005) and International Pharmaceutical Abstracts (1971-September 2005) for articles relating to the efficacy and tolerability of once-monthly ibandronate in the treatment of postmenopausal osteoporosis was conducted using the terms ibandronate and ibandronic acid. Additional searches were conducted to identify publications relevant to compliance and pharmacoeconomic considerations using the terms bispbospbonate, compliance, cost, and pharmacoeconomics. The reference lists of identified articles and presentations from recent scientific meetings also were reviewed. Selected safety information from the manufacturer was incorporated.

RESULTS

Ibandronate 2.5 mg/d and intermittent ibandronate (20 mg QOD for 12 doses every 3 months) have been shown to effectively reduce the incidence of vertebral fractures; after 3 years of therapy in a placebo-controlled clinical trial, the relative risk reductions for new vertebral fractures with daily and intermittent ibandronate were 62% and 50%, respectively (both, P<0.001 vs placebo). Once-monthly ibandronate has been evaluated in 2 clinical trials: a Phase I dose-ranging trial in 144 healthy postmenopausal women and a Phase III noninferiority trial in 1609 women with postmenopausal osteoporosis who were randomized to receive ibandronate 2.5 mg/d or 1 of 3 monthly ibandronate regimens: 50/50 mg (50 mg given on 2 consecutive days) once monthly; 100 mg once monthly; and 150 mg once monthly. The primary end point of the Phase III trial was the change from baseline in lumbar spine bone mineral density (BMD). After 1 year of therapy, patients who received ibandronate 150 mg once monthly had a significantly greater increase from baseline in lumbar spine BMD compared with those who received ibandronate 2.5 mg/d (4.9% vs 3.9%, respectively; P=0.002). The overall adverse-event profile was similar between the daily and monthly regimens. Drug-related adverse events were reported in 32.4% of patients receiving ibandronate 2.5 mg/d and 36.9% of patients receiving ibandronate 150 mg monthly. Upper gastrointestinal adverse events occurred in a respective 22.8% and 22.5% of the 2 groups. After 1 year of therapy, patients receiving ibandronate 150 mg monthly reported more flulike symptoms (8.3%) compared with those receiving ibandronate 2.5 mg/d (2.8%). In a crossover study comparing preference for and convenience of monthly ibandronate and weekly alendronate in 342 ambulatory women with postmenopausal osteoporosis, significantly more patients preferred the monthly ibandronate regimen to the weekly alendronate regimen (71.4% vs 28.5%, respectively; P<0.001).

CONCLUSION

Once-monthly ibandronate is an effective and well-tolerated treatment option for postmenopausal osteoporosis.

Review of adherence to medications for the treatment of osteoporosis

One of the major challenges of successful osteoporosis management is poor patient adherence to current therapies. Individuals who are nonadherent have significant consequences of reduced bone mineral density response, reduced bone marker suppression, and increased risk for fracture compared with individuals who are adherent. Although reducing the dosing interval from daily to weekly oral bisphosphonates has improved adherence, adherence with weekly bisphosphonates remains suboptimal. Barriers to adherence include patient health beliefs, inadequate patient education and age. Potential solutions include increased health care provider-patient interaction, and longer times between doses of medications.

Denosumab in postmenopausal women with low bone mineral density

BACKGROUND

Receptor activator of nuclear factor-kappaB ligand (RANKL) is essential for osteoclast differentiation, activation, and survival. The fully human monoclonal antibody denosumab (formerly known as AMG 162) binds RANKL with high affinity and specificity and inhibits RANKL action.

METHODS

The efficacy and safety of subcutaneously administered denosumab were evaluated over a period of 12 months in 412 postmenopausal women with low bone mineral density (T score of -1.8 to -4.0 at the lumbar spine or -1.8 to -3.5 at the proximal femur). Subjects were randomly assigned to receive denosumab either every three months (at a dose of 6, 14, or 30 mg) or every six months (at a dose of 14, 60, 100, or 210 mg), open-label oral alendronate once weekly (at a dose of 70 mg), or placebo. The primary end point was the percentage change from baseline in bone mineral density at the lumbar spine at 12 months. Changes in bone turnover were assessed by measurement of serum and urine telopeptides and bone-specific alkaline phosphatase.

RESULTS

Denosumab treatment for 12 months resulted in an increase in bone mineral density at the lumbar spine of 3.0 to 6.7 percent (as compared with an increase of 4.6 percent with alendronate and a loss of 0.8 percent with placebo), at the total hip of 1.9 to 3.6 percent (as compared with an increase of 2.1 percent with alendronate and a loss of 0.6 percent with placebo), and at the distal third of the radius of 0.4 to 1.3 percent (as compared with decreases of 0.5 percent with alendronate and 2.0 percent with placebo). Near-maximal reductions in mean levels of serum C-telopeptide from baseline were evident three days after the administration of denosumab. The duration of the suppression of bone turnover appeared to be dose-dependent.

CONCLUSIONS

In postmenopausal women with low bone mass, denosumab increased bone mineral density and decreased bone resorption. These preliminary data suggest that denosumab might be an effective treatment for osteoporosis. (ClinicalTrials.gov number, NCT00043186.).

Adherence and persistence: impact on outcomes and health care resources

Non-adherence to and poor persistence with antiresorptive medication are significant problems in preventing adverse consequences of osteoporosis. Adherence rates for oral bisphosphonate therapy drop off dramatically during the first year of treatment and continue to decline thereafter. Inadequate adherence is associated with smaller decreases in rate of bone turnover, smaller bone mineral density (BMD) gains, and greater risk of fracture. Measures to improve patient adherence include improved physician/patient communication, close monitoring, and early intervention in declining adherence. Another approach is strengthening of patient commitment through reinforcement of the connection between treatment response and quality of life benefits. Use of biochemical markers of response or BMD measurements to illustrate response to patients may be useful in this regard. Simplification of treatment regimens would also be of considerable value in improving adherence and persistence.

Bone loss in epilepsy: barriers to prevention, diagnosis, and treatment

In epilepsy populations there are multiple barriers to the prevention, diagnosis, and treatment of metabolic bone disease. This study explored issues that may be unique to inner-city care. We screened 101 consecutive patient charts from our clinic to identify barriers to optimal care. According to the Health Belief Model, when patients view a condition as not severe and their perceived susceptibility is low, they are unlikely to comply with screening and/or adopt preventative behaviors. Despite routine communications to primary care doctors regarding bone health, its importance is still overlooked. In addition, the managed care referral process makes it difficult for a specialist to prevent, screen, and treat a primary care condition with no symptoms. For optimal patient care and to stimulate prevention and screening compliance, a communication style adapted to the patient's knowledge, beliefs, and attitudes toward antiepileptic drug-induced bone loss is crucial to help reduce barriers against change.

Ibandronate: the evolution of a once-a-month oral therapy for postmenopausal osteoporosis

Bisphosphonates have been shown to be highly effective in preventing and treating postmenopausal osteoporosis (PMO) and the associated risk of fracture. However, poor adherence with bisphosphonate therapies for PMO results in a high incidence of otherwise preventable fractures. The chronicity of this condition requires long-term treatment, but fewer than one in two women remains on daily bisphosphonate therapy for 1 yr. A good way to reduce the risk of osteoporotic fractures is through development of equally efficacious formulations with more convenient dosing regimens. Weekly formulations of bisphosphonates have been introduced that demonstrate comparable efficacy to daily formulations with slightly improved adherence. Recently, a new formulation utilizing a third-generation nitrogen-containing bisphosphonate--ibandronate--has been approved with a monthly dosing regimen. The pharmacokinetics and high potency of ibandronate, similar with other bisphosphonates, facilitate lower mg doses and longer-interval dosing frequencies with similar efficacy and enhanced tolerability. Preclinical studies and clinical trials have consistently demonstrated that it is the total cumulative dose of ibandronate that determines efficacy. The convenience of once-monthly dosing may ultimately improve adherence and clinical outcomes among the growing population of postmenopausal women at risk of osteoporosis.

Zoledronic acid in the treatment of Paget's disease and other benign bone disorders

Zoledronic acid is a potent bisphosphonate widely used to counteract cancer-related bone loss. Once-yearly or even less frequent doses may be an effective therapy for benign bone disorders and may also result in improved compliance and tolerability. Data from two Phase III clinical trials have demonstrated the efficacy and safety of zoledronic acid in the treatment of Paget's disease of bone. Other studies have provided preliminary evidence for the utility of zoledronic acid in osteoporosis and other benign bone disorders. The major adverse effects associated with zoledronic acid infusions are transient flu-like symptoms. Ongoing clinical trials will provide key data on the ability of this agent to treat osteoporosis and prevent fractures in high-risk patients and on its long-term safety profile.

Compliance with drug therapy for postmenopausal osteoporosis

INTRODUCTION

Patient compliance with pharmacotherapy for osteoporosis is typically poor in clinical practice; less frequent dosing with bisphosphonates may improve compliance.

METHODS

Using data from 49 US health plans, we identified all women aged >/=45 years with osteoporosis who initiated therapy with a bisphosphonate, calcitonin, estrogen, or raloxifene. Compliance was examined alternatively in terms of incidence of adherence failure (medication days <80% of possible) and persistence failure (gap in therapy >/=90 days), and was compared across treatment groups using Kaplan-Meier methods and Cox proportional hazards models.

RESULTS

The study population included 18,822 women, 48% of whom initiated weekly bisphosphonate therapy. Overall risk of adherence failure was 47% at 3 months, 70% at 1 year, and 84% at 3 years. Risk of persistence failure was 47% at 1 year, and 77% at 3 years. In multivariate analyses, risk of adherence failure was higher for calcitonin (hazard ratio=2.7 vs weekly bisphosphonate therapy, p<0.01), but comparable for all other therapies. Relative risks of persistence failure were generally similar.

CONCLUSIONS

Approximately three-quarters of women who initiate osteoporosis drug therapy are non-adherent with treatment within 12 months, and almost 50% have discontinued such therapy by this time. Compliance with weekly bisphosphonate therapy is generally no better than that with osteoporosis medications requiring more frequent dosing.

Persistence with weekly alendronate therapy among postmenopausal women

INTRODUCTION

Although clinical trials indicate that oral bisphosphonates reduce osteoporotic fracture risk, compliance with bisphosphonate therapy in practice is suboptimal, with 1-year discontinuation rates exceeding 50%.

METHODS

We conducted a retrospective cohort study among female members of a large integrated health care delivery system (Kaiser Permanente of Northern California), age 45 years and older, to determine their persistence with weekly alendronate (defined as continuous use, allowing for a refill gap of 60 days), predictors of discontinuation, and subsequent osteoporosis therapy. We also examined the effect of varying the refill gap from 30 to 120 days on the discontinuation rate. From 2002 through 2003, we identified 13,455 women (age 68.8+/-10.4 years) who initiated weekly oral alendronate therapy.

RESULTS

Using a 60-day refill gap, the 1-year discontinuation rate was 49.6% [95% confidence interval (CI) 48.8-50.4%]; this increased to 58.0% (CI 57.2-58.8%) with a 30-day gap and decreased to 42.2% (CI 41.1-43.0%) with a 120-day gap. Among those who discontinued therapy, about one-third restarted alendronate or another osteoporosis drug within 6 months. Baseline factors associated with alendronate discontinuation included prior bone mineral density testing [adjusted odds ratio (OR) 0.64, CI 0.60-0.69], prior postmenopausal hormone therapy (OR 0.78, CI 0.73-0.84), prior high-dose oral glucocorticoid therapy (OR 1.26, CI 1.05-1.51), prior gastrointestinal diagnoses (OR 1.21, CI 1.09-1.36), and high number of therapeutic classes of prescriptions filled in the prior year (OR 1.21, CI 1.10-1.32), although the final model had limited explanatory power.

CONCLUSIONS

We conclude that apparent discontinuation rates are high within 1 year after treatment initiation, although a subset of women appears to restart bisphosphonate or other osteoporosis therapy. Because intermittent use and/or poor adherence is common, discontinuation rates based on data from administrative databases are sensitive to the refill gap length. In addition, we identified no clinical factors highly predictive of discontinuation.

Determinants of adherence to osteoporosis treatment in clinical practice

INTRODUCTION

Poor adherence to prescribed treatments is widespread in clinical practice and this can lead to potentially life-threatening events. This problem is apparently very common for osteoporosis treatment but the causes of discontinuation and low compliance are complex and poorly defined.

METHODS

Global adherence to osteoporosis treatment was specifically addressed in a nation-wide survey carried out in 9851 postmenopausal women referred to 141 Italian centres for osteoporosis management for a follow-up assessment, at least one year after having been prescribed a treatment with one of the following drugs: calcium+/-vitamin D supplements alone (CaVitD), hormone replacement therapy (HRT), raloxifene 60 mg (RLX), intramuscular clodronate 100 mg/7-14 days (CLOD), risedronate 5 mg/day (RIS) and alendronate 10mg/daily (ALN10) or 70 mg once weekly (ALN OW).

RESULTS

Overall 19.1% of the patients discontinued the prescribed drug before attending the bone mass re-evaluations, more than half of them within the first 6 months. The discontinuation rate was significantly different between the treatments. The medications most frequently interrupted within one year were CLOD (28.7%; p<0.01 versus any other treatment), while by far the least interrupted was ALN-OW (6.9%; p<0.001 versus any other treatment). The most frequent reasons for discontinuation were drug related side effects, insufficient motivation to treatment and fear of side effects. The prevalence of the reasons for discontinuation were different among treatments: safety concerns were very common for HRT, lack of motivation was the most common cause for CaVitD and CLOD, and drug related side effects for RIS, ALN and RLX. Persistence to treatment was significantly higher in patients with previous vertebral fractures, densitometric osteoporosis, on corticosteroid or anti-inflammatory treatments. A significantly increased risk of treatment interruption was found among patients on benzodiazepine or gastro-protective agents and in patients in whom a bone measurement was not readily available. The highest compliance to recommended dosing was observed with ALN OW and HRT (p<0.001 versus any other) and the lowest for CaVitD (p<0.01 versus any other). Poor treatment compliance (<50% drug taken) was significantly related to benzodiazepine and gastroprotective use, while a significantly better compliance was associated with recognized risk factors for osteoporosis: early menopause, low bone mass values values, previous vertebral fractures. The poorest adherence was observed when treatments were prescribed by General practitioners (GPs), and orthopaedic surgeons (p<0.01 versus global mean).

CONCLUSIONS

The results of this large survey of Italian osteoporotic women indicates that the most important determinant of both persistence and compliance to treatment is the type of drug prescribed with a definite advantage of ALN-OW. Treatment compliance is particularly poor for CaVitD and this emphasizes the need for new ways to supplement at least vitamin D. The main reasons for discontinuation are side effects and lack of motivation while the best treatment adherence was observed in patients with severe and well documented osteoporosis.

Persistence with teriparatide in patients with osteoporosis: the UK experience

INTRODUCTION

The objective of this paper was to determine the persistence with teriparatide at 12 months in all patients in the UK who were prescribed the treatment since its launch.

METHODS

Virtually all patients prescribed teriparatide in the UK receive treatment through Healthcare at Home, Basingstoke, UK. Data was obtained to assess the start date, discontinuation date and reason for discontinuation in all patients receiving teriparatide since its launch. Persistence was defined as the number of patients continuing treatment.

RESULTS

A total of 1,104 patients were included in the analysis. The median duration of use in all patients was 252 days. Of the 435 patients who were at least 12 months post-initiation of treatment, persistence was 87%. Forty-two patients (3.8%) had discontinued treatment due to adverse events.

CONCLUSIONS

This study demonstrates that persistence with teriparatide at 12 months is very high and is probably greater than that of existing oral therapies for osteoporosis. The reasons for the high persistence rates seen with teriparatide are likely to be multi-factorial. The high persistence rates should help to optimise the effectiveness of therapy in this group of high-risk patients.