Influence of socioeconomic factors on the adherence of alendronate treatment in incident users in Norway

The interruption of romosozumab treatment during COVID lockdown among US post-menopausal women enrolled in Medicare

PURPOSE

To evaluate the impact of the COVID lock-down on treatment interruptions of romosozumab, a first in class biologic therapy, administered by healthcare providers once monthly.

METHODS

We used Medicare data from 1/1/2017 to 9/30/2021 to identify women age ≥65 initiating romosozumab between 4/1/2019 and 6/30/2021. Patient demographics, provider specialty, and baseline comorbidities were identified. Romosozumab dispensations were grouped into five 6-month periods based on the dispensing date from FDA licensure to the end of the data (Period 1 to 5). "Treatment interruption" was defined as any interval gap between 2 dispensations >60 days. The numbers of treatment interruption event were aggregated per period per patient. Mixed effect Poisson regression with patient-level random effects was performed, including an interaction term between Period and number of prior doses.

RESULTS

There were 12,216 romosozumab new users identified. A total of 2724 treatment interruption events were identified among 2229 romosozumab users. After adjustment, comparing with the period immediately before the lockdown (Period 2: 2019-10-1-2020-3-30), the IRRs (95 % CI) for treatment interruption were 0.49 (0.29, 0.81), 1.65 (1.48, 1.85), 1.79 (1.60, 2.01), and 1.67 (1.49, 1.87) for periods 1, 3, 4, and 5, respectively, per 1 prior dose change (p < 0.01 for all IRRs), where Periods 3, 4, and 5 were post-lockdown.

CONCLUSION

Compared to the pre-COVID period, the lockdown negatively impacted the continuity of romosozumab treatment among Medicare beneficiaries. Prioritizing in-time assistance for patients receiving a provider-administered parenteral therapy is critical when patients' in-person access to their provider is compromised.

Improving the quality of the fracture liaison service through the implementation of a structured health record

OBJECTIVE

According to the best practice framework for secondary fracture prevention, all patients aged ≥50 years with a fracture should be assessed for osteoporosis within the fracture liaison service (FLS). The framework includes an FLS quality registry database to ensure quality. The input of data into our FLS registry was time-consuming and required entering data twice: into both the journal record and the registry. A '3-in-1' solution was required: (1) developing a structured health record (SHR) to provide decision-support to FLS nurses during patient consultations; (2) making a structured journal record from the SHR and (3) exporting data to the quality registry database. The SHR needed to be web based, secure and available for use all over the world.

DESIGN

One provider at Stavanger University Hospital met all the criteria for further development of the record (CheckWare). An interdisciplinary working group was established, following the Plan-Do-Study-Act working model. Depending on the answers given, the FLS nurses were provided decision-making support. A significant loss of height (≥4 cm) was highlighted as one of the process quality indicators. All clinically relevant data were summarised in a report, which was exported to the health record software. Data were exported to the FLS quality registry.

RESULTS

All fracture patients in need of a dual-energy X-ray absorptiometry scan received an appointment at the FLS outpatient clinic and 96% attended. The minimum standard was met for the three quality indicators 1-3). In particular, the use of SHRs increased the number of patients investigated for vertebral fractures with a height loss ≥4 cm from 67% to 93%.

CONCLUSION

The SHR was successful in regard to the '3-in-1' solution: providing decision support to FLS nurses, developing structured journal records and exporting data to the FLS quality registry. After implementation, all FLS registry quality indicators improved.

Utilization of screening and treatment for osteoporosis among stroke survivors

BACKGROUND

Stroke survivors are prone to osteoporosis and fractures. However, bone mineral density (BMD) testing and osteoporosis treatment were underutilized in patients with recent stroke. We aimed to examine whether stroke has an impact on the utilization of BMD testing and osteoporosis treatment as well as the determinants of their utilization in stroke patients using nationwide population-based data in Taiwan.

METHODS

We identified patients aged 55 years and older who were hospitalized for hemorrhagic or ischemic stroke as the stroke cohort, and age- and sex-matched patients hospitalized for reasons other than stroke, fracture, or fall as the non-stroke cohort. We used the Fine-Gray sub-distribution hazard competing risk regression model to determine the predictors for BMD testing and osteoporosis treatment.

RESULTS

A total of 32997 stroke patients and 32997 age- and sex-matched controls comprised the stroke and non-stroke cohorts, respectively. BMD testing and osteoporosis treatment were performed in 1.0% and 5.2% of the stroke patients, respectively, within one year after hospitalization while these measures were performed in 0.8% and 4.7% of the controls. Stroke patients were more likely to receive BMD testing (adjusted hazard ratio [HR] 1.33; 95% confidence interval [CI] 1.11-1.58) and osteoporosis treatment (adjusted HR 1.19; 95% CI 1.11-1.29). Female sex, osteoporosis, prior BMD testing, and low-trauma fractures after stroke increased the likelihood of using BMD testing and osteoporosis treatment whereas greater stroke severity reduced the likelihood of receiving both measures.

CONCLUSIONS

Both BMD testing and osteoporosis treatment were underutilized among stroke survivors even though they had a higher chance of receiving both measures than non-stroke patients.

Does treatment with bisphosphonates protect against fractures in real life? The HUNT study, Norway

Bisphosphonates reduce fractures in randomized controlled trials (RCT); however, there is less information from real life. In our population including 14,990 women and 13,239 men, use of bisphosphonates reduced risk of fractures in hip and forearm in women. The magnitude of the effect was comparable to results from RCT.

INTRODUCTION

The objective was to examine if treatment with bisphosphonates (BPs) was associated with reduced risk of fractures in the hip and forearm in women and men in the general population.

METHODS

In a cohort study based on data from the third wave of the population-based HUNT Study (HUNT3), the fracture registry in Nord-Trøndelag, and the Norwegian Prescription Database, 14,990 women and 13,239 men 50-85 years were followed from the date of participating in HUNT3 (2006-2008) until the date of first fracture in the hip or forearm, death, or end of study (31 December 2012). Hazard ratios with 95% confidence intervals for hip and forearm fracture according to use of BPs were estimated using Cox proportional hazards models with time-dependent exposure. Adjustment for individual FRAX® fracture risk assessment scores was included.

RESULTS

BPs, predominantly alendronate, were used by 9.4% of the women and 1.5% of the men. During a median of 5.2 years of follow-up, 265 women and 133 men had a hip fracture, and 662 women and 127 men had a forearm fracture. Compared with non-users of BPs, the hazard ratios with 95% confidence interval for a fracture among users of BPs adjusted for age and FRAX® were 0.67 (0.52-0.86) for women and 1.13 (0.50-2.57) for men. Among users of glucocorticoids, the corresponding figures were 0.35 (0.19-0.66) and 1.16 (0.33-4.09), respectively.

CONCLUSIONS

Use of BPs was associated with reduced risk of fractures in hip and forearm in women, and the magnitude of effect is comparable to results from RCTs.

Comparing the efficacies of bisphosphonates' therapies for osteoporosis persistence and compliance: A Systematic Review

OBJECTIVES

Osteoporosis is the most prevalent metabolic bone disorder worldwide. This review was undertaken to compare the efficacies of bisphosphonates therapies for patient persistence and compliance for the treatment of osteoporosis.

METHODS

A systematic review was performed in accordance with the available reporting items. MEDLINE and Cochrane library databases were applied for literature searched up to January 2020. All major studies such as prospective, retrospective and reviews articles that examined patient persistence or compliance to bisphosphonates for osteoporosis were included.

RESULTS

Literature search found 656 relevant published reports, out of which 87 were included. The 10,712,176 osteoporotic patients were studied for patient persistence and 5,875,718 patients were studied for patient compliances. Analysis of all studied bisphosphonates showed almost similar patterns for patient persistence rates as it was decreased over the time following initial prescription but persistence length was found to be significantly high for alendronate therapy as compared to the other studied bisphosphonates (p<0.001), whereas the length of persistence of all other bisphosphonates (other than alendronate) were almost same (p>0.05). Analysis of patient compliances with etidronate therapy showed the highest percent medication possession ratio (MRP) at 12 months, followed by the MRPs of ibandronate, alendronate, risedronate, and clodronate.

CONCLUSIONS

This is the first systematic review that shows the comparison of the efficiencies of bisphosphonates for patient persistence and compliance for the treatment of osteoporosis. The data showed that the length of patient persistence was highest for alendronate therapy, whereas patient compliance was highest for etidronate therapy for the treatment of osteoporosis.

Irrational use of alendronate sodium by the elderly

Introduction: The effectiveness and safety of alendronate sodium are dependent on patient adherence to very specific guidelines regarding use. This study aims to estimate the rational use of alendronate sodium in the elderly. Methods: This is a cross-sectional study carried out with a structured questionnaire containing form of use and occurrence of adverse events related to alendronate sodium. The patients were recruited in their own homes. Rational use was considered as being the participants who: a) took the tablet in the morning; b) were fasting; c) waited at least 30 minutes before eating; d) ingested with a full glass of water; e) ingested the whole tablet; f) and remained in the orthostatic position for at least 30 minutes after use. Additionally, the odds ratio (OR) was used to analyze the association between the irrational use of alendronate sodium and the independent variables. Results and Discussion: Of the 248 participants in the study, most of the participants administered the medication in the morning (95.2%), with fasting (89.1%), waited at least 30 minutes to eat the first meal of the day (87.9%), and were in the orthostatic position until the time of the first meal (78.6%), but less than half ingested the tablet with a full glass of water (43.6%). Rational use of the medication was observed in only 30.7% of the participants. Regarding possible adverse events, 13.3% of the participants reported some event. Among the most prevalent were dry cough (6.5%), stomach pain (5.2%) and some throat discomfort (4.8%). The irrational use of this medication is associated with age and education level. Conclusion: The prevalence of irrational use of alendronate sodium in the elderly is high, and this use is associated with patients’ sociodemographic factors.

Initiation of anti-osteoporotic drugs in high-risk female patients starting glucocorticoid treatment: a population study in Norway

Glucocorticoid use is a risk factor for osteoporosis and fractures. We studied whether women initiating glucocorticoid treatment also started anti-osteoporotic treatment, according to clinical guidelines. Women with versus without previous fracture were twice as likely to start anti-osteoporotic treatment within 1 year after initiating glucocorticoid treatment, but the cumulative incidences were low 9.1% vs. 4.6%, respectively.

PURPOSE

Use of glucocorticoids (GC) is a risk factor for osteoporosis and fractures, and clinical guidelines suggest that preventive treatment with anti-osteoporotic drugs (AOD) should be considered when starting GC. Women with high risk of osteoporosis comprise those with previous fractures or a known inflammatory rheumatic disease, for whom the indication of AOD is even stronger. The purpose of these analyses was to investigate whether women initiating GC treatment also started AOD, especially those with high risk of osteoporosis.

METHODS

We used data from the Norwegian Prescription Database to identify all women 55 years and older initiating GC treatment in Norway during 2010-2016 and to obtain information on use of AOD. Data from the Norwegian Patient Registry were used to obtain information on previous fractures and diagnoses.

RESULTS

Among 105,477 women initiating GC treatment during 2010-2016, 3256 had started AOD and 79,638 had discontinued GC treatment after 1-year follow-up. Cumulative incidence of starting AOD after 1 year was 9.1% (95% CI: 7.9, 10.4) for women with vs. 4.6% (95% CI: 4.4%, 4.8%) for women without a previous fracture. Women with rheumatoid arthritis or another inflammatory rheumatic disease were more likely to start AOD than women with other indications. For the whole cohort, the probability of starting AOD treatment within 1 year after initiating GC increased on average 3% per year (HR = 1.03, CI: 1.01, 1.05) from 2010 to 2016.

CONCLUSIONS

Having had a previous fracture or an inflammatory rheumatic disease increased the probability of treatment with AOD. However, the proportions starting AOD were much lower than clinically indicated.

The challenge of long-term adherence: The role of bone turnover markers in monitoring bisphosphonate treatment of osteoporosis

Oral Bisphosphonates (BPs) are the mainstay of osteoporotic treatment, however long-term adherence remains a challenge, primarily owing to the chronic character of the disease and the regimen complexity. Poor compliance has been shown to have a clear link to fracture risk. The role of bone turnover markers (BTMs) as a tool to ascertain adherence and response to therapy is supported by their rapid response to treatment; a decrease in values is witnessed within days or weeks of commencing treatment. A greater reduction of serum CTX and NTX is evidenced with alendronate and ibandronate compared to risedronate. A change in bone formation BTMs appears to be related to vertebral fracture risk reduction, whereas no significant relationship is evident for hip and non-vertebral fractures. The utility of BTMs as an adjunct for monitoring withdrawal of treatment with oral BP has also been suggested. Finally, studies evaluating BTMs as an intervention, failed to demonstrate any effect on adherence. This review explores the challenge of long-term adherence with bisphosphonates and provides an analytic framework with respect to the role of BTMs in monitoring bisphosphonate treatment, adherence and the offset of treatment effect.

The Association of Oral Bisphosphonate Use With Mortality Risk Following a Major Osteoporotic Fracture in the United Kingdom: Population-Based Cohort Study

OBJECTIVES

Bisphosphonates (BPs) might have extra benefits in reducing mortality because of their anti-atherosclerotic effects, but studies reported conflicting results. We investigated the association between oral BP use and mortality risk following a major osteoporotic fracture (MOF) in the United Kingdom.

DESIGN

This was a population-based cohort study.

SETTING AND PARTICIPANTS

In total, 163,273 adults aged 50 years and older with an MOF between 2000 and 2018 from the Clinical Practice Research Datalink in the United Kingdom.

METHODS

Cox proportional hazards models were used to estimate the risk of all-cause mortality in current (0‒6 months), recent (7‒12 months), and past (>1 year) exposures to oral BPs after nonhip MOF and hip fracture. In addition, stratification by sex, BP type, and duration of follow-up was performed.

RESULTS

Compared with never users of oral BPs, current BP use was associated with a 7% higher all-cause mortality risk after nonhip MOF, whereas a 28% lower all-cause mortality risk was observed after hip fracture. Past BP exposure was associated with a 14% and 42% lower risk after nonhip MOF and hip fracture, respectively. When considering only the first 5 years of follow-up, mortality risk associated with current BP use was significantly lower for both fracture groups, and the greatest reduction in mortality risk was observed within the first year. Women had slightly lower risk compared with men.

CONCLUSIONS AND IMPLICATIONS

We found a slight increased risk of all-cause mortality with current BP exposure after a nonhip MOF; however, a protective effect was observed following a hip fracture. Both the timing and the effect size of an association based on the anti-atherosclerotic hypothesis of BPs are not supported by our results. The decreasing trend of the mortality risk with shorter durations of follow-up suggests that the observed association is likely due to unknown distortion or unknown pleiotropic properties of BPs.

Real-world persistence and adherence with oral bisphosphonates for osteoporosis: a systematic review

OBJECTIVES

This study examined patient adherence and persistence to oral bisphosphonates for the treatment of osteoporosis in real-world settings.

METHODS

A systematic review was completed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Medical Literature Analysis and Retrieval System Online (MEDLINE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine Database (AMED), Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment (HTA) and National Health Service Economic Evaluation Database NHS EED) databases were searched for studies published in English language up to April 2018. Prospective and retrospective observational studies that used prescription claim databases or hospital medical records to examine patient adherence and persistence to oral bisphosphonate treatment among adults with osteoporosis were included. The Newcastle-Ottawa quality assessment scale (NOS) was used to assess the quality of included studies.

RESULTS

The search yielded 540 published studies, of which 89 were deemed relevant and were included in this review. The mean age of patients included within the studies ranged between 53 to 80.8 years, and the follow-up varied from 3 months to 14 years. The mean persistence of oral bisphosphonates for 6 months, 1 year and 2 years ranged from 34.8% to 71.3%, 17.7% to 74.8% and 12.9% to 72.0%, respectively. The mean medication possession ratio ranged from 28.2% to 84.5%, 23% to 50%, 27.2% to 46% over 1 year, 2 years and 3 years, respectively. All studies included scored between 6 to 8 out of 9 on the NOS. The determinants of adherence and persistence to oral bisphosphonates included geographic residence, marital status, tobacco use, educational status, income, hospitalisation, medication type and dosing frequency.

CONCLUSIONS

While a number of studies reported high levels of persistence and adherence, the findings of this review suggest that patient persistence and adherence with oral bisphosphonates medications was poor and reduced notably over time. Overall, adherence was suboptimal. To maximise adherence and persistence to oral bisphosphonates, it is important to consider possible determinants, including characteristics of the patients.

A systematic review of factors affecting medication adherence among patients with osteoporosis

The aim of this review was to identify factors that influence patients' adherence to anti-osteoporotic therapy. Factors identified that were associated with poorer medication adherence included polypharmacy, older age, and misconceptions about osteoporosis. Physicians need to be aware of these factors so as to optimize therapeutic outcomes for patients.

INTRODUCTION

To identify factors that influence patients' adherence to anti-osteoporotic therapy.

METHODS

A systematic review of literature was performed for articles published up till January 2018 using PubMed®, PsychINFO®, Embase®, and CINAHL®. Peer-reviewed articles which examined factors associated with anti-osteoporotic medication adherence were included. Classes of anti-osteoporotic therapy included bisphosphonates, parathyroid hormone-related analogue, denosumab, selective estrogen receptor modulators, estrogen/progestin therapy, calcitonin, and strontium ranelate. Meta-analyses, case reports/series, and other systematic reviews were excluded. Identified factors were classified using the World Health Organization's five dimensions of medication adherence (condition, patient, therapy, health-system, and socio-economic domains).

RESULTS

Of 2404 articles reviewed, 124 relevant articles were identified. The prevalence of medication adherence ranged from 12.9 to 95.4%. Twenty-four factors with 139 sub-factors were identified. Bisphosphonates were the most well-studied class of medication (n = 59, 48%). Condition-related factors that were associated with poorer medication adherence included polypharmacy, and history of falls was associated with higher medication adherence. Patient-related factors which were associated with poorer medication adherence included older age and misconceptions about osteoporosis while therapy-related factors included higher dosing frequency and medication side effects. Health system-based factors associated with poorer medication adherence included care under different medical specialties and lack of patient education. Socio-economic-related factors associated with poorer medication adherence included current smoker and lack of medical insurance coverage.

CONCLUSION

This review identified factors associated with poor medication adherence among osteoporotic patients. To optimize therapeutic outcomes for patients, clinicians need to be aware of the complexity of factors affecting medication adherence.

Assessment of geriatric predictors of adherence to Zoledronic acid treatment for osteoporosis: a prospective follow-up study

Objectives Discontinuation of bisphosphonate treatment remains high even with the long acting parenteral options. Whether there are some unidentified causes of noncompliance more specific to aged individuals is unknown. The aim of this study was to investigate baseline predictors of adherence to Zoledronic acid (ZOL) infusions among non-demented older adults with osteoporosis. Methods Patients aged ≥ 65 years who received a first ever ZOL infusion for osteoporosis were prospectively enrolled. Risk factors for osteoporosis and fractures, comorbidities, geriatric assessment measures, including depression, and anticholinergic burden were determined at baseline. Adherence was defined as taking the next ZOL infusion at 12 months. Results A total of 187 participants were included (mean age: 75.7 ± 6.3 years, female: 77.5%). Adherence to the next ZOL infusion was 66.8% (n = 125). Non-adherent participants (n = 62, 33.2%) had significantly higher frequency of historical height decrease and depression at baseline. Poor adherence was associated with height decrease, presence of depression, and higher anticholinergic burden in univariate analysis. After adjustment for relevant confounders, fragility fracture history (OR: 0.38, 95%CI: 0.17-0.86, p = 0.020), depression (OR: 0.32, 95%CI: 0.12-0.82, p = 0.018), and higher anticholinergic burden (OR: 0.67, 95%CI: 0.49-0.93, p = 0.017) were the predictors of lower adherence to ZOL infusion. Conclusions The rate of adherence to the next ZOL infusion was still suboptimal among older women and men in this study. Past osteoporotic fractures, depression, and higher anticholinergic drug burden predicted poor ZOL adherence. It was a novel finding that drug-related anticholinergic side effects adversely influenced adherence to another medication without anticholinergic properties.

Anti-osteoporosis drug use: too little, too much, or just right? The HUNT study, Norway

Use of anti-osteoporotic drugs (AODs) was examined in a Norwegian population 50-85 years. Among them with Fracture Risk Assessment Tool (FRAX) score for major osteoporotic fracture ≥ 20, 25% of the women and 17% of the men received AODs. The strongest predictors for AODs were high age in women and use of glucocorticoids among men.

INTRODUCTION

To examine the use of anti-osteoporotic drugs (AODs) and to identify predictors for prescriptions.

METHODS

Data were obtained from the Nord-Trøndelag Health Study (HUNT3) performed in 2006-2008 and the Norwegian Prescription Database, including 15,075 women and 13,386 men aged 50-85 years. Bone mineral density (BMD) in the femoral neck was measured in a subgroup of 4538 women and 2322 men. High fracture risk was defined as a FRAX score for major osteoporotic fracture (MOF) ≥ 20%; in the subgroup with BMD, high risk was in addition defined as FRAX_MOF ≥ 20% or T-score ≤ - 2.5. Hazard ratios (HRs) for predictors of incident use of AODs within 2 years after HUNT3 were estimated by Cox' proportional hazards model.

RESULTS

Among individuals with FRAX MOF ≥ 20%, 25% of the women and 17% of the men were treated with AODs. Among those with FRAX MOF < 20%, 3% and 1% were treated, respectively. In the subgroup with BMD measurement, 24% of the women and 16% of the men at high risk of fractures were treated, compared to 3 and 1% in women and men not fulfilling the criteria. In women, high age was the strongest predictor for treatment (HR 3.84: 95% confidence interval 2.81-5.24), followed by use of glucocorticoids (GCs) (2.68:1.84-3.89). In men, predictors were use of GCs (5.28: 2.70-10.35) followed by multimorbidity (3.16:1.31-7.63). In the subgroup with BMD, T-score ≤ - 2.5 was the strongest predictor (women 3.98:2.67-5.89; men 13.31:6.17-28.74).

CONCLUSIONS

This study suggests an undertreatment of AODs in individuals at high risk of fracture.

Adherence and persistence of patients using oral bone sparing drugs in primary care

AIM

Studies based on pharmacy medication records have shown suboptimal adherence and persistence of osteoporosis treatment with oral bone sparing drugs (OBSD). Little is known about adherence and persistence of OBSD treatment in primary care. We assessed adherence and persistence of OBSD use of patients in general practices and identified associated factors.

METHODS

Using electronic medical records, adherence and persistence of newly prescribed treatment with OBSD in patients from 16 general practices was retrospectively assessed. The Medication Possession Ratio (MPR) was calculated as a proxy for adherence (MPR > 75%), persistence rates were estimated using survival analysis. Determinants of adherence and persistence using logistic regression and Cox regression analysis were assessed.

RESULTS

OBSD treatment was initiated in 957 patients. Seventy-five percent and 45% of the patients persisted OBSD treatment for one and five years, respectively. Being adherent in the first year decreased the risk of long-term non-persistence [hazard ratio (HR) 0.41; 95% confidence interval (CI) 0.3-0.57; P < 0.001]. Patients receiving the majority of their prescriptions by a specialist tended to be more non-persistent (HR 1.37; 96%; CI 0.96-1.94; P = 0.08). Adherence was 62.5% in the first year and 60.8% in the overall treatment period. Non-adherence was associated with the specialist being the main prescriber [odds ratio (OR) 3.76; 95% CI 2.43-5.82; P < 0.001] and younger age (<65 years, OR 1.44; 95% CI 1.01-2.08; P = 0.04).

CONCLUSION

Older age of the patients and the GP prescribing the majority of medication were associated with better adherence and persistence. Good adherence in the first prescription year was associated with better persistence.

Women's lived experiences of learning to live with osteoporosis: a longitudinal qualitative study

Background

A vast amount of literature exists concerning pharmaceutical adherence in osteoporosis. However, the process of learning to live with osteoporosis over time remains largely unknown. The purpose of this study was to gain a deeper understanding of the continued process of how women learn to live with osteoporosis. Our objective was to explore what characterizes women’s experiences of living with osteoporosis during the first year after diagnosis, when patients are prescribed anti-osteoporotic treatment, without having experienced an osteoporotic fracture.

Methods

Forty-two narrative qualitative interviews were conducted with fifteen recently diagnosed Danish women. A longitudinal design was chosen since this allows an investigation of the perspective over time. The interviews were conducted in the period of March 2011 to August 2012. Data were analyzed using a phenomenological-hermeneutic interpretation of text. No medical records were available for the researchers. All information with the exception of T-score was self-reported.

Results

The participants’ experiences could be described in two key themes developed through the analysis: 1) “To become influenced by the medical treatment” which consisted of two sub-themes “taking the medication”, and “discontinuing the medication”. 2) “Daily life with osteoporosis”, which was characterized by three sub-themes: “interpretation of symptoms”, “interpretation of the scan results” and “lifestyle reflections”. The results highlighted that learning to live with osteoporosis is a multifaceted process that is highly influenced by the medical treatment. In some cases, this is a prolonged process that can take around one year.

Conclusions

The results suggest a need for improved support for individual women during the complex process of learning to live with osteoporosis. The study adds new knowledge that can be useful for healthcare professionals taking a health-oriented stance when supporting women in self-management of their illness. Further investigations of lived experiences over time in the field of osteoporosis research are therefore needed.

Electronic supplementary material

The online version of this article (doi:10.1186/s12905-017-0377-z) contains supplementary material, which is available to authorized users.

Non-adherence with bisphosphonates among patients with osteoporosis: impact on fracture risk and healthcare cost‏

Osteoporosis-related fractures at the spine and hip have a substantial impact on mortality, morbidity, and quality of life in older adults worldwide. Adherence to bisphosphonates is essential for effective treatment and fracture prevention. Nevertheless, numerous studies from various populations and study designs clearly indicated that adherence and persistence are poor with more than 50% of patients discontinuing therapy within one year. This is primarily explained by mild adverse effects, dosing regimens, and costs. Studies have also shown that good adherence is associated with reduced osteoporosis-related and non-related healthcare costs as soon as 2 years from therapy initiation. Nonetheless, we found only little improvement in adherence rates over the years. In light of the importance of medication adherence and the limited success of previous programs, other than reducing dosing frequency, new directions should be explored to engage patients and care givers in order to improve adherence and prevent fractures.

Natural history, reasons for, and impact of low/non-adherence to medications for osteoporosis in a cohort of community-dwelling older women already established on medication: a 2-year follow-up study

Approximately 15 % of older women on oral medications for osteoporosis could be considered for alternatives including parenteral therapies. Collection of data on socio-demographic/clinical variables is unlikely to be helpful in predicting low/non-adherence. Alternative approaches are needed to identify individuals at risk of low/non-adherence.

INTRODUCTION

This study aims to identify individual patient reasons for stopping medications for osteoporosis, and to investigate whether this can be predicted from knowledge about socio-demographic/clinical data, or whether alternative approaches need to be used.

METHODS

The Cohort for Skeletal Health in Bristol and Avon (COSHIBA) recruited 3200 older women from South West UK, of whom a proportion were on medications for osteoporosis at baseline. Information on self-reported adherence and reasons for low/non-adherence were collected at 6-monthly intervals over a 2-year period. Data was also collected on potential predictors of and impact of low/non-adherence.

RESULTS

Two hundred thirty-three of 3200 (7.3 %) women were on medications for osteoporosis at baseline. Mean length of time on treatment prior to enrolment was 46 months. Of those on osteoporosis medications, 94.9 % were on bisphosphonates; 8.5 % reported low adherence and 21.6 % stopped their medication completely over the 2-year follow-up period. Length of time on medication at baseline did not influence rates of low/non-adherence. Reasons for low/non-adherence to bisphosphonates included side effects (53.9 %), practical reasons such as forgetting to take them (18.0 %) and beliefs about medications (20.5 %). No convincing predictors of low/non-adherence were identified.

CONCLUSIONS

Approximately 15 % of older women on oral medications for osteoporosis could be considered for alternatives including parenteral therapies. This has important implications for healthcare provision. Collection of data on socio-demographic/clinical variables is unlikely to be helpful in predicting low/non-adherence. Alternative approaches are needed to identify individuals at risk of low/non-adherence to osteoporosis medications.

Educational Inequalities in Post-Hip Fracture Mortality: A NOREPOS Study

Hip fractures are associated with high excess mortality. Education is an important determinant of health, but little is known about educational inequalities in post-hip fracture mortality. Our objective was to investigate educational inequalities in post-hip fracture mortality and to examine whether comorbidity or family composition could explain any association. We conducted a register-based population study of Norwegians aged 50 years and older from 2002 to 2010. We measured total mortality according to educational attainment in 56,269 hip fracture patients (NORHip) and in the general Norwegian population. Both absolute and relative educational inequalities in mortality in people with and without hip fracture were compared. There was an educational gradient in post-hip fracture mortality in both sexes. Compared with those with primary education only, the age-adjusted relative risk (RR) of mortality in hip fracture patients with tertiary education was 0.82 (95% confidence interval [CI] 0.77-0.87) in men and 0.79 (95% CI 0.75-0.84) in women. Additional adjustments for Charlson comorbidity index, marital status, and number of children did not materially change the estimates. Regardless of educational attainment, the 1-year age-adjusted mortality was three- to fivefold higher in hip fracture patients compared with peers in the general population without fracture. The absolute differences in 1-year mortality according to educational attainment were considerably larger in hip fracture patients than in the population without hip fracture. Absolute educational inequalities in mortality were higher after hip fracture compared with the general population without hip fracture and were not mediated by comorbidity or family composition. Investigation of other possible mediating factors might help to identify new targets for interventions, based on lower educational attainment, to reduce post-hip fracture mortality.

Use of anti-osteoporotic drugs in central Norway after a forearm fracture

Use of anti-osteoporotic drugs (AOD) the first year after a forearm fracture in central Norway was low in the period 2005-2012. Women with fractures used more AOD compared to the general population only in 2006, 2007, and 2011. Female gender, age ≥ 60 years, use of glucocorticosteroids, or ≥ 4 different drugs were associated with AOD use.

PURPOSE

The primary aim of this study was to examine time trends in prevalence and incidence of AOD use the first year after a forearm fracture from 2005-2012. Further, secondary aims were to investigate if gender, the number of drugs used before fracture, or use of glucocorticoids influenced the prescription of AOD, and to examine adherence to AOD.

METHODS

Data is from the fracture registry in Nord-Trøndelag and the Norwegian Prescription database, including women (N = 1434) and men (N = 513) 40-84 years with their first forearm fracture between 2005 and 2012. AOD were defined as bisphosphonates, teriparatide, denosumab, and raloxifene. Prevalence and incidence were calculated, and prevalent use among women with forearm fracture was compared with the population in Nord-Trøndelag and Norway. Age-adjusted Poisson regression analyses for time trends and odds ratio for treatment with AOD was estimated. Adherence was defined as medication possession ratio ≥ 80 %.

RESULTS

The first year after the fracture, 11.2 % of the women and 2.7 % of the men were prevalent users, while 5.1 % and 1.2 %, respectively, were incident users of AOD. Bisphosphonates comprised 98.8 %. AOD use among women with fractures was significantly higher compared to the general population in Nord-Trøndelag only in 2006, 2007, and 2011. There was a trend towards a decline in AOD use among women with fractures from 2005 to 2012 (coefficient -0.05, p = 0.15). Female gender, age ≥ 60 years, use of glucocorticosteroids, or ≥ 4 different drugs the last year before fracture were associated with AOD use. In women, 54.8 % were adherent during 3 years after fracture.

CONCLUSIONS

The use of AOD after a forearm fracture was low. An increased focus on osteoporosis in fracture patients is needed for secondary fracture prevention.

Gender- and body-site-specific factors associated with bone mineral density in a non-institutionalized Korean population aged ≥50 years

The aim of this study was to investigate the gender- and body-site-specific factors associated with bone mineral density (BMD) at the femoral neck and lumbar spine in a non-institutionalized population aged ≥50 years characterized by low average calcium intake. The comprehensive data utilized were from the 2010 Fifth Korea National Health and Nutrition Examination Survey, which included health behavior questionnaire, blood and urine tests, dual-energy X-ray absorptiometry, and nutrition intake. The factors associated with BMD at the femoral neck and lumbar spine in both genders were analyzed separately using multiple regression analysis with a stepwise selection. The average daily calcium intake in the male subjects was 565.8 mg and in the female subjects was 443.7 mg. In multiple regression analysis, age, body mass index (BMI), alkaline phosphatase (ALP), lead, daily calcium intake, and cadmium were the significant factors associated with femoral neck BMD in male subjects. BMI, creatinine (Cr), total body fat percentile, lead, ALP, and hypertension were found to be the significant factors associated with lumbar spine BMD in male subjects. In the female subjects, the significant factors associated with femoral neck BMD were age, BMI, ALP, house income, and total body fat percentile, while menopause, Cr, mercury, house income, BMI, and ALP were found to be the significant factors associated with lumbar spine BMD. In conclusion, different factors were associated with BMD depending on gender and the body site tested (femoral neck or lumbar spine). These gender- and body-site-specific factors need to be considered for the prevention and management of osteoporosis.

Socioeconomic disparities in osteoporosis prevalence: different results in the overall Korean adult population and single-person households

OBJECTIVES

The present study was conducted in order to examine the association between socioeconomic status (SES) and osteoporosis prevalence in Korea and to assess whether different associations are found in single-person households.

METHODS

A cross-sectional population-based study was conducted using the Korea National Health and Nutrition Examination Survey, from 2008 to 2011. The study subjects were people aged ≥ 50 years with osteoporosis as defined by bone mineral density. Multivariate logistic models were used to estimate prevalence odds ratios (pORs) and 95% confidence intervals (CIs). Gender differences in the likelihood of osteoporosis were analyzed based on household income, education level, and residential area.

RESULTS

There were 8221 osteoporosis patients aged ≥ 50 years, of whom 927 lived in single-person households. There was a gender-specific association between osteoporosis prevalence and all three SES factors that we analyzed: income, education, and residential area. After adjusting for age, SES, and health behaviors, including body mass index (BMI), low household income was only significantly associated with osteoporosis in men, whereas education level had an inverse relationship with osteoporosis only in women (p = 0.01, p < 0.001, respectively). However, after controlling for age and BMI, rural residency was only associated with osteoporosis in women living in single-person households (pOR, 1.59; 95% CI, 1.05 to 2.43).

CONCLUSIONS

The Korean adult population showed a gender-specific relationship between SES and osteoporosis prevalence, with a different pattern found in single-person households.

[The lack of adherence to antiosteoporotic drugs: crossing methods, the key to adherence measurement?]

OBJECTIVE

To use two different techniques to assess adherence of patients treated with antiosteoporotic drug.

METHODS

This monocentric transversal study was performed on a 6 months period, on patients of a single French pharmacy treated with antiosteoporotic drugs. Adherence was assessed crossing 2 techniques (patient autoquestionnaire and medication possession ratio measurement). Statistical analysis consisted in a description of the population study and a multivariate logistic regression to identify the factors associated with a lack of observance.

RESULTS

Using the two techniques, the lack of adherence was estimated to be between 14 and 55%. Adherence was better in patients who were given dietetic advice or information about the usefulness of physical activity and worse in patients who reached menopause less than 23 years ago.

CONCLUSION

A better identification of patients with a lack of observance is possible by crossing several techniques to assess adherence of the patient to his antiosteoporotic drug.

A systematic review of osteoporosis medication adherence and osteoporosis-related fracture costs in men

BACKGROUND AND OBJECTIVE

Male osteoporosis is an increasingly important public health concern. Although several medications are approved for the treatment of osteoporosis, medication non-adherence and the associated consequences are not well documented in male populations. Our objective was to identify and summarize the current knowledge related to osteoporotic medication adherence, the potential implications of non-adherence to the medication, and the cost of osteoporosis-related fractures and health-resource utilization in men.

METHODS

Two separate systematic searches were conducted concurrently: one to identify literature reporting male-specific adherence to anti-osteoporotic medication and the clinical consequence of non-adherence in men, and the other to identify literature reporting the cost and resource burden of osteoporosis-related fractures in men. The PubMed, MEDLINE, EMBASE, and Cochrane databases were searched using a date range of 1 January 1998 to 30 June 2012, and citations were screened based on pre-defined criteria.

RESULTS

The percentage of males adherent to bisphosphonates [medication possession ratio (MPR) >0.8] over a 1-year period ranged from 32% to 64%. The data imply worse clinical outcomes with treatment non-adherence. Costs and resource use associated with osteoporosis-related fractures in men are high, with hip fractures generating the most cost.

CONCLUSIONS

One-third to two-thirds of men are not adherent to bisphosphonates. Non-adherence is associated with increased fracture risk. Estimates of direct and indirect osteoporosis-related fracture costs are also substantial in men, and may even be more costly than in women. More robust data would better inform disease management initiatives that could improve adherence to medication and outcomes in men with osteoporosis.

Adherence to osteoporosis regimens among men and analysis of risk factors of poor compliance: a 2-year analytical review

BACKGROUND

To investigate adherence and patient-specific factors associated with poor compliance with osteoporosis regimens among men.

METHODS

In this retrospective chart review study, we collected data on male patients with osteoporosis treated in accordance with therapeutic recommendations. Adherence was determined by the compliance and persistence of those patients who had been dispensed an osteoporosis regimen after an index prescription. All osteoporosis regimens were considered equivalent for the purpose of investigating adherence.

RESULTS

The prescriptions of 333 males met the inclusion criteria for data collection. The mean age was 68.6 ± 10.4 years. The median medication possession ratio (MPR, %) at years 1 and 2 was 90.1% (interquartile range (IQR) 19-100) and 53.7% (IQR 10.4-100), respectively; 52.3% of male patients at year 1 and 37.5% at year 2 had good compliance (defined as a MPR≧80%). The 1- and 2-year persistence rates were 45.9% and 30.0%, respectively. Patient-specific factors associated with poor compliance (MPR < 80%) during year 1 were first prescriptions given by orthopedists (odds ratio (OR) = 2.67; 95% confidence interval (CI) = 1.58-4.53; adjusted OR = 2.30, 95% CI = 1.26-4.22, p = 0.007). Male patients with rheumatoid arthritis (RA) (OR = 0.22, 95% CI = 0.06-0.78, adjusted OR = 0.19, 95% CI = 0.04-0.81, p = 0.025) and baseline bone mineral density (BMD) measurements (OR = 0.52, 95% CI = 0.32-0.85; adjusted OR = 0.51; 95% CI = 0.28-0.93, p = 0.029) were less likely to have poor compliance.

CONCLUSIONS

Adherence to osteoporosis regimens in males was suboptimal in our study. Poor compliance was more likely in prescription of the first anti-osteoporotic regimen by an orthopedist. Men with RA and BMD measurements before therapy had a lower risk of non-adherence. Healthcare professionals need to target patients with specific factors to improve adherence to osteoporotic regimens.

Anti-osteoporotic therapy in Denmark--predictors and demographics of poor refill compliance and poor persistence

In this study of 100,949 new users of oral bisphosphonates age ≥ 35 years, "early quitters" were found to differ from others with poor refill compliance in terms of socioeconomic, demographic, and treatment-related characteristics. New risk factors for poor compliance and persistence were identified.

INTRODUCTION

Poor compliance with anti-osteoporotic therapy is an on-going worldwide challenge. In this study, we hypothesized that "early quitters" differ in socioeconomics, demographics, co-medications, and comorbid conditions from other patients with low compliance.

METHODS

The study was a register-based nationwide cohort study of anti-osteoporotic therapy comprising 100,949 men and women. Statistical analysis including backward stepwise logistic regression analysis was used to explain causes of treatment failure and Kaplan-Meier survival analysis to estimate persistence of treatment.

RESULTS

It was noted that 56.6 % of the patients were persistent and compliant, 4.7 % of the patients were persistent but "low compliant" while 38.7 % of the patients were "early quitters". "Early quitters" were found to differ in socioeconomics from "low compliant" patients. Differences concerning increased risk of "early quitters" were associated with high household income, subjects' age 71.9-79 years, living in the countryside or village, prior treatment with analgesics and anti-parkinson drugs, and dementia. Differences concerning decreased risk of "early quitters" were associated with male, living in an apartment, children living at home, living close to a university hospital, anti-osteoporotic therapy other than alendronate, number of drugs especially above three, pulmonary disease, collagen disease.

CONCLUSION

The results suggest a need for improved support for patients to facilitate the interpretation of the disease and the perception of the benefits and risks of treatment-to reduce the risk of "early quitters". We were able to identify new risk groups that may be candidates for targeted actions.

Bisphosphonates adherence for treatment of osteoporosis

BACKGROUND

Osteoporosis is a disease of bone metabolism in which bisphosphonates (BPS) are the most common medications used in its treatment, whose main objective is to reduce the risk of fractures. The aim of this study was to conduct a systematic review on BPs adherence for treatment of osteoporosis.

METHODS

Systematic review of articles on BPs adherence for treatment of osteoporosis, indexed on MEDLINE (via PubMed) databases, from inception of databases until January 2013. Search terms were "Adherence, Medication" (MeSH term), "Bisphosphonates" (MeSH term), and "Osteoporosis" (MeSH term).

RESULTS

Of the 78 identified studies, 27 met the eligibility criteria. Identified studies covered a wide range of aspects regarding adherence and associated factors, adherence and fracture, adherence and BPs dosage. The studies are mostly observational, conducted with women over 45 years old, showing low rates of adherence to treatment. Several factors may influence adherence: socio-economic and cultural, participation of physicians when guidance is given to the patient, the use of bone turnover markers, and use of generic drugs. The monthly dosage is associated with greater adherence compared to weekly dosage.

CONCLUSIONS

Considering the methodological differences between the studies, the results converge to show that adherence to treatment of osteoporosis with BPs is still inadequate. Further experimental studies are needed to evaluate the adherence and suggest new treatment options.