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Koller G, Goetz V, Vandermeer B, Homik J, McAlister FA, Kendler D, Ye C. Persistence and adherence to parenteral osteoporosis therapies: a systematic review. Osteoporos Int 2020; 31:2093-2102. [PMID: 32613409 DOI: 10.1007/s00198-020-05507-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/15/2020] [Indexed: 12/18/2022]
Abstract
Osteoporosis is a chronic disease of low bone mass and fragility. Treatment is frequently compromised by suboptimal medication compliance causing increased morbidity. This review investigates adherence and persistence to parenteral osteoporosis therapies. Findings reveal parenteral medications requiring reduced dosing frequency have higher compliance than oral therapies. This systematic review examines real-world adherence to parenteral osteoporosis therapies. We searched PubMed, Medline, and EMBASE databases for English language observational studies that examined patient adherence and/or persistence to parenteral osteoporosis treatments (teriparatide sc, ibandronate iv, zoledronic acid iv, and denosumab sc) in adults with osteoporosis published up to September 2018. Studies with only self-reported adherence or persistence data and those with less than 20 patients were excluded. Quality assessment of included studies was completed using the Newcastle-Ottawa quality assessment scale (NOS). We identified 40 eligible studies. Teriparatide was examined in 29 studies, with persistence rates of 10-87% (median 55%) at 1 year and 10-69% (median 29.5%) at 2 years, and adherence rates of 21-89% (median 53%) at 1 year and 37-68% (median 40%) at 2 years. Ten studies of zoledronic acid reported persistence rates of 34-73% (median 42%) for second dose and 20-54% (median 35.8%) for third dose. Ten studies of ibandronate adherence reported and 2-year persistence rates of 31-58% (median 47.5%) in 1 year and 13-35% (median 25%) at 2 years, and adherence rates of 21-72% (median 47.3%) and 15-58% (median 36.5%) respectively. Denosumab was reported in 19 studies, with second (1 year) and fourth (2 year) dose persistence rates of 61-100% (median 81%) and 36-99% (median 45.5%). There is substantial heterogeneity in reports of persistence and adherence rates with parenteral osteoporosis therapies. Most of the published data are from short-term studies and evaluations of long-term adherence and persistence with parenteral therapies for osteoporosis are needed.
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Affiliation(s)
- G Koller
- Department of Medicine, Division of Rheumatology, University of Alberta, 8-130 Clinical Sciences Building, 11350 83rd Avenue NW, Edmonton, AB, T6G 2G3, Canada
| | - V Goetz
- Department of Medicine, Division of Rheumatology, University of Alberta, 8-130 Clinical Sciences Building, 11350 83rd Avenue NW, Edmonton, AB, T6G 2G3, Canada
| | - B Vandermeer
- Alberta Research Centre for Health Evidence, Biostatistician, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - J Homik
- Department of Medicine, Division of Rheumatology, University of Alberta, 8-130 Clinical Sciences Building, 11350 83rd Avenue NW, Edmonton, AB, T6G 2G3, Canada
| | - F A McAlister
- Department of Medicine, Division of General Internal Medicine, University of Alberta, Edmonton, AB, Canada
| | - D Kendler
- Department of Medicine, Division of Endocrinology, University of British Columbia, Vancouver, BC, Canada
| | - C Ye
- Department of Medicine, Division of Rheumatology, University of Alberta, 8-130 Clinical Sciences Building, 11350 83rd Avenue NW, Edmonton, AB, T6G 2G3, Canada.
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Jepsen DB, Masud T, Holsgaard-Larsen A, Hansen S, Jørgensen NR, Ryg J. The combined effect of parathyroid hormone (1-34) and whole-body vibration exercise on physical performance in OSteoporotic women (PaVOS study): a secondary analysis from a randomised controlled trial. BMC Sports Sci Med Rehabil 2020; 12:54. [PMID: 32944251 PMCID: PMC7487945 DOI: 10.1186/s13102-020-00204-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 08/27/2020] [Indexed: 11/10/2022]
Abstract
Background The aim of this study was to investigate the effect on physical performance of combining whole-body vibration exercise (WBV) with parathyroid hormone 1-34 (teriparatide) compared to teriparatide alone. Methods A secondary analysis from a RCT where postmenopausal women with severe osteoporosis were randomised to WBV plus teriparatide (intervention) or teriparatide alone (control). WBV was applied three times/week (6x1min WBV:1 min rest, (peak acceleration 3.6 g)) for twelve months. Both groups received teriparatide 20 μg s.c./day. The primary endpoint (bone mineral density) is reported elsewhere. Physical performance measures (Short Physical Performance Battery (SPPB), Timed-Up-and-Go (TUG), leg extension power, and grip strength) were obtained at baseline, three-, six-, and twelve months, lean mass at baseline and twelve months. Data were analysed with mixed linear regression model or robust cluster regression in an intention to treat analysis. Results Thirty-five women aged (mean ± SD) 69 ± 7) years were recruited of which thirty-two (91%) completed the twelve months follow-up (WBV + teriparatide = 15, teriparatide = 17). SPPB score (mean ± SD) improved significantly at three months in the WBV + teriparatide group from 9.13 ± 2.03 to 10.35 ± 1.69 (p = 0.014) with a statistical trend towards a between-group change in favor of the WBV + teriparatide group (0.86 [95%CI(- 0.05,1.77), p = 0.065]). Both groups improved in leg extension power during the study period whereas no changes were seen in TUG, grip strength, or lean mass in either group. No statistical significant between-group differences were observed. Conclusion WBV may improve some short-term aspects of physical performance in severely osteoporotic postmenopausal women who are receiving teriparatide treatment. Trial Registration ClinicalTrials.gov, ID:NCT02563353.
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Affiliation(s)
- Ditte Beck Jepsen
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Tahir Masud
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Geriatric Medicine, Nottingham University Hospitals Trust NHS, Nottingham, UK
| | - Anders Holsgaard-Larsen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Orthopaedics and Traumatology, Odense University Hospital, Odense, Denmark
| | - Stinus Hansen
- Department of Endocrinology, Hospital South West Jutland, Esbjerg, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Niklas Rye Jørgensen
- Department of Clinical Biochemistry, Rigshospitalet, Copenhagen, Denmark.,OPEN- Odense Patient data Explorative Network, Odense University Hospital/ University of Southern Denmark, Odense, Denmark
| | - Jesper Ryg
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Høiberg MP, Rubin KH, Holmberg T, Rothmann MJ, Möller S, Gram J, Bech M, Brixen K, Hermann AP. Use of antiosteoporotic medication in the Danish ROSE population-based screening study. Osteoporos Int 2019; 30:1223-1233. [PMID: 30911782 DOI: 10.1007/s00198-019-04934-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 03/05/2019] [Indexed: 10/27/2022]
Abstract
UNLABELLED Use of antiosteoporotic medication in the population-based, risk-stratified osteoporosis strategy evaluation (ROSE) screening study, comparing the use of FRAX followed by DXA with usual care, was examined. Screening increased the overall use of medication. Being recommended treatment by the hospital and higher age increased the likelihood of starting medication, but, nevertheless, a large percentage opted not to start treatment. INTRODUCTION The aim of the study was to examine the impact on medication prescription, adherence, and persistence of osteoporotic medicine in the randomized population-based ROSE screening study for osteoporosis. METHODS The Danish ROSE study included a population-based random sample of women aged 65-81 years randomized to either a two-step screening program consisting of FRAX followed by DXA for high-risk participants or opportunistic screening for osteoporosis (usual care). This sub-study on the intention-to-treat population examined the impact of the screening program on antiosteoporotic medication redemption rates, adherence, and persistence using Danish registers. RESULTS A total of 30,719 of 34,229 women were treatment-naïve. Significantly more participants in the screening group started on antiosteoporotic medication, but no differences in adherence and persistence rates were found. Higher age was associated with a higher likelihood of starting medication. A low Charlson comorbidity score (= 1) was associated with higher treatment initiation but lower adherence and persistence of antiosteoporotic treatment. A total of 31.7% of participants advised to initiate treatment did not follow the advice. CONCLUSIONS Screening for osteoporosis using FRAX followed by DXA increased the overall use of antiosteoporotic medication in the screening group without differences in adherence and persistence rates. A large percentage of participants advised to initiate treatment did nevertheless fail to do so.
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Affiliation(s)
- M P Høiberg
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
- Department of Research, Hospital of Southern Norway, Egsveien 4, N-4604, Kristiansand, Norway.
| | - K H Rubin
- OPEN - Odense Patient Data Explorative Network, Department of Clinical Research, University of Southern Denmark and Odense University Hospital, Odense, Denmark
| | - T Holmberg
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - M J Rothmann
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
- Department of Rheumatology, Odense University Hospital, Odense, Denmark
| | - S Möller
- OPEN - Odense Patient Data Explorative Network, Department of Clinical Research, University of Southern Denmark and Odense University Hospital, Odense, Denmark
| | - J Gram
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Endocrinology, Hospital of Southwest Denmark, Esbjerg, Denmark
| | - M Bech
- VIVE - The Danish Center for Social Science Research, Copenhagen, Denmark
| | - K Brixen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - A P Hermann
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
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Yeam CT, Chia S, Tan HCC, Kwan YH, Fong W, Seng JJB. A systematic review of factors affecting medication adherence among patients with osteoporosis. Osteoporos Int 2018; 29:2623-2637. [PMID: 30417253 DOI: 10.1007/s00198-018-4759-3] [Citation(s) in RCA: 111] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 10/30/2018] [Indexed: 01/18/2023]
Abstract
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.
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Affiliation(s)
- C T Yeam
- Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
| | - S Chia
- Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
| | - H C C Tan
- Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
| | - Y H Kwan
- Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
- Program in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
| | - W Fong
- Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
- Department of Rheumatology and Immunology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - J J B Seng
- Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore.
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Taisne N, Mignot MA, Legroux I, Cortet B, Paccou J. Teriparatide persistence and tolerance in patients with osteoporosis: Observational data from clinical practice. Joint Bone Spine 2018; 85:641-642. [DOI: 10.1016/j.jbspin.2018.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2017] [Indexed: 10/18/2022]
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Usui T, Funagoshi M, Seto K, Ide K, Tanaka S, Kawakami K. Persistence of and switches from teriparatide treatment among women and men with osteoporosis in the real world: a claims database analysis. Arch Osteoporos 2018; 13:54. [PMID: 29725863 DOI: 10.1007/s11657-018-0466-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Accepted: 04/18/2018] [Indexed: 02/03/2023]
Abstract
UNLABELLED This study investigated the real-world persistence rate and switches of teriparatide-treated patients using a claims database in Japan. The persistence rate of teriparatide at 12 months was 34.9%, and approximately one-third of the patients were not treated with any osteoporosis drugs after teriparatide. Improvement in persistence and switches are desired. PURPOSE We aimed to elucidate the persistence rates and switches before and after teriparatide treatment in real-world osteoporosis patients based on data from a medical claims database in Japan. METHODS We reviewed the records of patients with diagnoses of osteoporosis who were prescribed teriparatide at least once from January 2005 to June 2017. Patients with a follow-up ≤ 90 days before the first and ≤ 90 days after the last prescription of teriparatide were excluded. Discontinuation was defined as no treatment for > 90 days. We investigated treatment duration, compared characteristics of patients with persistence ≤ 12 and > 12 months, and osteoporotic medications before and after teriparatide by weekly or daily teriparatide. RESULTS Among the 553 patients extracted for the study, 81.9% were women, 45.6% were aged ≥ 65 years, and 67.3% had a fracture. The most common fracture site was the spine (39.2%). The overall persistence rate of teriparatide > 12 months was 34.9% (weekly, 23.5%; daily, 43.1%). The subjects with persistence > 12 months comprised a higher proportion of women and they had a higher prevalence of rib and sternum fractures than those with ≤ 12 months. After teriparatide, 38.2% were switched to active vitamin D3, 35.1% to bisphosphonates, and 13.7% to denosumab allowing duplication. However, 34.0% of the patients were not switched to any subsequent medication for osteoporosis. CONCLUSIONS Persistence rate over 12 months of teriparatide treatment was 34.9% in Japan. Approximately one-third of patients had no subsequent treatment immediately after teriparatide. Monitoring persistence and considering subsequent drugs for osteoporosis are necessary for teriparatide treatment.
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Affiliation(s)
- Tomoko Usui
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Masaru Funagoshi
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Kahori Seto
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Kazuki Ide
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan.,Center for the Promotion of Interdisciplinary Education and Research, Kyoto University, Kyoto, Japan
| | - Shiro Tanaka
- Clinical Biostatistics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Koji Kawakami
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan.
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Huang TW, Chuang PY, Lin SJ, Lee CY, Huang KC, Shih HN, Lee MS, Hsu RWW, Shen WJ. Teriparatide Improves Fracture Healing and Early Functional Recovery in Treatment of Osteoporotic Intertrochanteric Fractures. Medicine (Baltimore) 2016; 95:e3626. [PMID: 27175673 PMCID: PMC4902515 DOI: 10.1097/md.0000000000003626] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Osteoporotic intertrochanteric fractures result in serious health problems and decrease health-related quality of life (HRQoL). Faster time-to-union is important for early return to daily activities and reduction of complications. Teriparatide has been shown to accelerate fracture healing, but the literature is sparse on this topic. The aim of this study is to assess whether teriparatide accelerates fracture healing.Between 2008 and 2014, patients with osteoporotic intertrochanteric fractures who underwent surgical interventions were enrolled in this retrospective cohort study. Group 1 included patients who were not on any osteoporosis medication prior to fracture and who postoperatively received only calcium and vitamin D; patients in Group 2 were not on any osteoporosis medication prior to fracture, and received teriparatide and calcium and vitamin D postoperatively. Patients in Group 3 were those who were on alendronate prior to fracture and postfracture received teriparatide as well as calcium and vitamin D. Demographics, time-to-union, HRQoL (short-form health survey [SF]-12 physical component summary [PCS] and SF-12 mental component summary [MCS]), morbidities, mortalities, and radiographic and functional outcomes between groups were compared.A total of 189 patients were enrolled in this study. There were 83 patients in Group 1, 47 patients in Group 2, and 59 patients in Group 3. A significantly shorter time-to-union was found in the teriparatide-treated groups (mean, 13.6, 12.3, and 10.6 weeks, respectively [P = 0.002]). With regard to SF-12 PCS, the scores were significantly better in teriparatide-treated groups at 3 months (mean, 19, 28, and 29, respectively [P = 0.002]) and 6 months (mean, 28, 37, and 38, respectively [P = 0.008]). Similar inter-group differences were noted when comparing the pain scores, the ability to get around the house, the ability to get out of the house, and the ability to go shopping at 3 and 6 months. Complications and mortality were also markedly reduced in the teriparatide-treated groups.Postoperative use of teriparatide for 6 months appears to be an effective adjunct therapy in the treatment of patients with osteoporotic intertrochanteric fractures. However, because of the limited power of the study, a prospective, randomized, large-scale cohort study is still required for determining the efficacy of teriparatide.
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Affiliation(s)
- Tsan-Wen Huang
- From the Department of Orthopedic Surgery (T-WH, P-YC, S-JL, C-YL, K-CH, RW-WH) and Sports Medicine Center (RW-WH), Chang Gung Memorial Hospital, Chiayi, Taiwan; Department of Orthopedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Taiwan (MSL); Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan (H-NS); Chang Gung University, Taoyuan, Taiwan (T-WH, K-CH, H-NS, MSL, RW-WH); and Po-Cheng Orthopedic Institute, Kaohsiung (W-JS), Taiwan
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Hadji P, Jacob L, Kostev K. Gender- and age-related treatment compliance in patients with osteoporosis in Germany. Patient Prefer Adherence 2016; 10:2379-2385. [PMID: 27920504 PMCID: PMC5125755 DOI: 10.2147/ppa.s118396] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
AIM The purpose of this study was to analyze treatment compliance in osteoporotic patients treated with osteoporosis medications in Germany. METHODS Patients included in the analysis had been diagnosed with osteoporosis with or without fractures and started anti-osteoporotic therapy (bisphosphonates, denosumab, or strontium ranelate) between 2011 and 2014 in a general (GP) or orthopedic practice (OP) setting in Germany. Data pertaining to 6,221 individuals followed in GP and 4,044 individuals followed in OP were analyzed retrospectively. The last follow-up was in December 2015. The main outcome measure was the compliance within the one-year period after the index prescription date. Compliance was measured indirectly and was based on the mean possession ratio (MPR). A multivariate logistic regression model was used to determine the association between MPR (dependent variable) and age, gender, type of practice, type of osteoporosis treatment, therapy frequency, and history of fracture (covariates). RESULTS The mean age of the study group was 73.3 years, and 13.2% of subjects were men. Regarding type of practice, 60.6% of individuals were followed in GP and 39.4% in OP. Noncompliance was observed in 55.2% of the patients. Patients in the age group ≤60 years were at a higher risk of being noncompliant when compared to those in the age group of 61-70 years. Men and patients who received oral drugs were also more likely to be noncompliant than women and patients who received injectable or intravenous drugs. Finally, therapies that were given every three or six months were associated with a decrease in the risk of noncompliance when compared to weekly therapy, whereas daily and monthly treatments were associated with an increased risk. CONCLUSION Compliance is insufficient in osteoporotic patients treated with osteoporosis medications.
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Affiliation(s)
- Peyman Hadji
- Department of Bone Oncology, Endocrinology and Reproductive Medicine, Nordwest Hospital, Frankfurt, Germany
| | - Louis Jacob
- Faculty of Medicine, University of Paris, Paris, France
| | - Karel Kostev
- Epidemiology, IMS Health GmbH & Co. Ohg, Darmstädter Landstraße, Frankfurt, Germany
- Correspondence: Karel Kostev, Epidemiology, IMS Health GmbH & Co. Ohg, Darmstädter Landstraße 108, 60598, Frankfurt am Main, Germany, Tel +49 69 6604 4878, Email
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