Overview of treatment approaches to osteoporosis

Efficient therapies are available for the treatment of osteoporosis. Anti-resorptive therapies, including bisphosphonates and denosumab, increase bone mineral density (BMD) and reduce the risk of fractures by 20-70%. Bone-forming or dual-action treatments stimulate bone formation and increase BMD more than the anti-resorptive therapies. Two studies have demonstrated that these treatments are superior to anti-resorptives in preventing fractures in patients with severe osteoporosis. Bone-forming or dual-action treatments should be followed by anti-resorptive treatment to maintain the fracture risk reduction. The BMD gains seen with bone-forming and dual-action treatments are greater in treatment-naïve patients compared to patients pretreated with anti-resorptive treatments. However, the antifracture efficacy seems to be preserved. Treatment failure will often lead to switch of treatment from orally to parentally administrated anti-resorptives treatment or from anti-resorptive to bone-forming or dual-action treatment. Osteoporosis is a chronic condition and therefore needs a long-term management plan with a personalized approach to treatment. LINKED ARTICLES: This article is part of a themed issue on The molecular pharmacology of bone and cancer-related bone diseases. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v178.9/issuetoc.

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.

Clinical setting influences patterns of interaction between osteoporosis patient and physician

The importance of healthy behavior for bone health, as well as low adherence to anti-osteoporosis medication are well-described problems. Both, lifestyle habits and compliance with drug-therapy are influenced by the relationship between patients and physicians. We analyzed 152 consecutive doctor-patient interactions conducted in public and private practices specialized in the management of osteoporosis. We recorded the duration of the consultation and the relative length of: (a) Personal and medical history collection, (b) Physical examination, (c) Explanation of the diagnosis and treatment modalities, and (d) Administrative tasks. The overall length and the respective duration of the four phases of the consultation significantly differ in private versus public practices. In the private practice, doctors spend more time with the patient and dedicate a higher proportion of their time to history collection and explanation of diagnosis/treatment for osteoporosis. While we do not integrate data on medication adherence, we believe that since more time is dedicated to health education, patients consulting in the private sector have a greater probability to adopt a healthy lifestyle and better/ longer take anti-osteoporosis medications. Further investigations are needed to assess if the differences in patient and doctor behaviors in the public-private settings have a significant impact on therapeutic adherence and subsequently fracture reduction in patients receiving anti-osteoporosis treatment.

Association between refill compliance to oral bisphosphonate treatment, incident fractures, and health care costs--an analysis using national health databases

SUMMARY

The study estimates the cost of poor and suboptimal refill compliance by estimating fracture costs and assessing the association between refill compliance with oral bisphosphonates and incident fractures using Danish health registers. Patients with poor and suboptimal refill compliance had more major osteoporotic fractures, and the direct costs related to hospital care, primary care, and pharmaceutical treatment for these excess fractures reached almost 14 M DKK (2.5 M USD) for the study population which compares to a national annual excess cost of around 17 M DKK (3.1 M USD) using 2011 prescription prevalence.

INTRODUCTION

Adherence to oral anti-osteoporosis treatment has been shown in several studies to be relatively low and the potential impact on fracture burden is high. The aim of the study was to assess the association between refill compliance and all-cause health care costs.

METHODS

A national dataset was extracted with all treatment-naive patients who began oral bisphosphonate (BP) treatment for osteoporosis in Denmark between 1997 and 2006 (N = 54,876, 87 % women). Patients who survived for at least 2 years (N = 47,176) were divided into groups based on Medication Possession Ratio (MPR). Logistic regressions were used to derive difference in the probability of incident fractures between the three MPR groups. Fracture costs (related to medication use, primary care practice, specialists, and hospitals) were derived by comparing cost 12 months before and after fracture.

RESULTS

For alendronate, the adjusted risk of major osteoporotic fractures was significantly reduced (OR 0.768; 0.686-0.859), including fractures of the hip (0.718; 0.609-0.846) and humerus (0.54; 0.431-0.677) with MPR ≥ 0.8. The risk reduction was lower with etidronate. Over 2 years, a total of 171 hip fractures and 53 other major osteoporotic fractures were attributed to suboptimal or poor refill compliance, with an excess cost of 13.7 M DKK (2.5 M USD).

CONCLUSIONS

Poor refill compliance is not unusual in patients on oral bisphosphonates, and we demonstrate that this is accompanied by excess major osteoporotic fractures and health care costs at the societal level.

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.

Patient self-reported adherence for the most common chronic medication therapy

Aims: The aims of this study was to determine adherence to chronic disease medication measured by self-reported questionnaire. Methods: The survey was conducted at 106 Zagreb pharmacies, and the questionnaire was filled out by the study subjects. Results: A total 1,357 diagnoses were reported by survey respondents (i.e., an average of 2.1 diagnoses per respondent). The most common diagnoses were diseases of the circulatory system ( n = 500; 36.8%). The great majority of study subjects reported forgetfulness (‘I just forgot’) as the main reason for skipping drug doses. Conclusions: Among the many reasons people give for not adhering to drug treatment, forgetfulness was the most common. Common barriers to adherence are under the patient’s control, so that attention to them is a necessary and important step in improving adherence. The existence of more than one cause of risk considerably increases the non-adherence risk of a patient.

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

PURPOSE

To examine whether socioeconomic factors influence adherence to alendronate drug treatment among incident users in Norway during 2005-2009.

METHODS

The study included 7610 incident alendronate users in 2005 (40-79 years), followed until 31 December 2009. Mean age was 66.6 years, and 86.7% of the patients were women. Data were drawn from the Norwegian Prescription Database and linked to marital status, education and income. Adherence was measured by the medication possession ratio (MPR). MPR was defined as the number of dispensed defined daily doses divided by the number of days each patient was included in the study. A patient was adherent if MPR ≥ 80%. ORs with 95%CI were estimated using logistic regression.

RESULTS

Among all patients, 45.5% was adherent throughout 4.2 years. A slightly higher proportion of women than men were adherent. Adjusted for all covariates, women aged 70-79 years had an OR of 1.27 (95%CI 1.10-1.45) for adherence compared with those 40-59 years. In women, high household income predicted adherence of alendronate use. In men, a middle educational level compared with a low level, predicted adherence (adjusted OR = 1.47 (95%CI 1.10-1.96)). After adjustments, previous marriage reduced the odds of being adherent compared with present marriage, in both men and women.

CONCLUSIONS

In women, the most important factors for being adherent were high age and high income. In men, a middle educational level predicted adherence. Previous marriage reduced the odds of being adherent in both women and men.

Self-reported adherence to medical treatment prior to and during pregnancy among women with ulcerative colitis

BACKGROUND

Adherence to medical treatment among women with ulcerative colitis (UC) prior to and during pregnancy has never been investigated. The aim was to examine predictors for and prevalence rates of nonadherence to maintenance treatment among women with UC prior to and during pregnancy.

METHODS

We identified 115 women with UC having given birth during 2000-2005 within a population of 1.6 million. They received a questionnaire about predictors and adherence and relapses were registered. We retrieved information on medical treatment from prescription databases and used logistic regression to estimate prevalence odds ratios (POR) for nonadherence by different predictors.

RESULTS

Among 93 (81%) respondents, 63 (68%) reported taking medication, 53 of whom had filled prescriptions for relevant medication, yielding a positive predictive value of self-reported use of medical treatment of 84.1% (95% confidence interval [CI] 72.7-92.1). Approximately 60% reported adhering to medical treatment. Those who received counseling regarding medical treatment were less likely to be nonadherent compared with no counseling, especially during pregnancy (POR 0.2, 95% CI 0.04-0.94). Of those who were nonadherent, fear of a negative effect on fertility/fetus was stated as the reason by 23% prior to and by 50% during pregnancy. Notably, 40.3% reported an episode of relapse during the pregnancy period, compared with 13.6% in the period 6 months prior to pregnancy.

CONCLUSIONS

Adherence was high despite fear of a negative effect on fertility or the fetus. Counseling predicted higher adherence. This may be important because our study suggests an increase in UC activity during pregnancy.