Patient compliance with alendronate, risedronate and raloxifene for the treatment of osteoporosis in postmenopausal women

The Efficacy of Selective Estrogen Receptor Modulators Monotherapies in Postmenopausal Women with Osteopenia

BACKGROUND

The impact of osteopenia as a risk factor for fractures is underrecognized. Moreover, the efficacy of selective estrogen receptor modulators (SERMs) in postmenopausal women with osteopenia is limited. This study aimed to evaluate the efficacy of SERMs in postmenopausal women with osteopenia.

METHODS

Thirty-two postmenopausal women with osteopenia were treated with 3 types of SERMs medication: raloxifene (group I, N=15), bazedoxifene (group II, N=8), and raloxifene with cholecalciferol (group III, N=9). Bone mineral density (BMD) was measured using dual energy X-ray absorptiometry scans before treatment to after 3 years of treatment once a year.

RESULTS

Patients in group I showed significant increases in hip BMD, -1.93 to -1.73 and spine BMD, -1.85 to -1.67. In addition, patients in groups II and III showed significant increases in hip BMD, -1.93 to -1.69 and -2.22 to -1.86, respectively and spine BMD, -2.1 to -1.3 and -2.22 to -1.37, respectively. The BMD increased in the hip and spine by 9.7% and 10.3%, respectively in group I, 38.0% and 12.4%, respectively in group II, and 38.2% and 16.2%, respectively in group III.

CONCLUSIONS

In this study, we found that SERMs could improve spine and hip BMD. In conclusion, preemptive treatment using SERMs is necessary for postmenopausal women with osteopenia. None of the patients experienced fractures during the follow-up period.

Osteoporotic Fractures among Selective Estrogen Receptor Modulator Users in South Korea: Analysis Using National Claims Database

Background

We evaluated (1) compliance with selective estrogen receptor modulator (SERM) use in postmenopausal women; and (2) the risk of osteoporotic fractures according to compliance and other patient characteristics.

Methods

National claims data of postmenopausal women from January 2013 to December 2014 were reviewed. Demographics, comorbidities, type of medical institution, and patient compliance were investigated. Compliance was measured according to medication possession ratio (MPR) and the patients were classified into compliant (MPR ≥80%) or non-compliant (MPR <80%) groups. Osteoporotic fractures were followed up for 2 years after prescription.

Results

Among 15,166 postmenopausal women, 4,130 were categorized as compliant. Osteoporotic fractures were confirmed in 669 patients. The hip fracture rate in the non-compliant group (0.39%) was marginally higher than that in the compliant group (0.36%; P=0.06). Compared to age 50 to 54 years, age 55 to 59 years showed protection against fractures (hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.379–0.857; P=0.007), while those over 70 years showed a higher risk of fractures (HR, 2.035; 95% CI, 1.485–2.789; P<0.0001 for age 70–74 years; HR, 2.197; 94% CI, 1.588–3.041; P<0.0001 for age 75–79 years; and HR, 3.53; 95% CI, 2.493–4.999; P<0.0001 for age ≥80 years). Patients with mild (HR, 1.29; 95% CI, 1.088–1.530; P=0.0034) and moderate (HR, 1.286; 95% CI, 1.002–1.652; P=0.0486) comorbidities were associated with higher risks of fractures compared to those without comorbidities.

Conclusions

Among postmenopausal women with osteoporosis, only 27.2% complied with SERM therapy. A marginal difference in hip fracture rate was observed between the compliant and non-compliant groups. Older age and severe comorbidities were associated with higher risks of osteoporotic fractures.

Quality of life and patient satisfaction with raloxifene/cholecalciferol combination therapy in postmenopausal women

This study was performed to evaluate quality of life (QOL) and patient satisfaction with raloxifene/cholecalciferol combination therapy in postmenopausal women with low bone mass. This multicenter, prospective, noninterventional observational study included 3907 postmenopausal women who received a combination of raloxifene 60 mg and cholecalciferol 800 IU daily to treat or prevent osteoporosis. Changes in QOL and patient satisfaction were evaluated after 3 and 6 months of treatment. In addition, the safety profile was assessed. Mean age was 67.7 ± 9.3 years old. QOL, assessed by European Quality of life instrument 5 Dimensions (EQ-5D) index, improved significantly after 3 months (0.81 ± 0.11, P < 0.001) and 6 months (0.82 ± 0.11, P < 0.001) of treatment compared to the baseline (0.78 ± 0.14). Improvement in QOL was also significant regardless of previous regimens both in women who were switched from other drugs (bisphosphonates or selective estrogen receptor modulators) and in women who received the study drug for the first time (P < 0.001 for all comparisons). Percentage of women satisfied with the effects (from 37.3 to 67.7%, P < 0.001) and convenience (from 42.8 to 74.1%, P < 0.001) of treatment compared to previous medication significantly increased after 6 months of treatment. In addition, serious adverse drug reactions did not occur, and hot flushes were observed only in 12 women (0.3%). Combination therapy with raloxifene and cholecalciferol significantly improves quality of life with no serious adverse events and high patient satisfaction at 6 months. Our real-world data suggest that this regimen is a promising option for postmenopausal women with low bone mass.

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.

Cost and health care resource use associated with noncompliance with oral bisphosphonate therapy: an analysis using Danish health registries

We estimated the rate of compliance with oral bisphosphonates among Danish women and examined its association with health care resource use and cost. Approximately 30 % of Danish females aged >55 who take bisphosphonates are noncompliant, and noncompliance is significantly associated with increased health care resource use and cost.

INTRODUCTION

Two objectives of this study were to estimate the rate of oral bisphosphonate compliance among Danish women and to examine the association of noncompliance with health care resource use and cost.

METHODS

Women ≥55 with an index prescription claim for an oral bisphosphonate were identified from Danish national health registries between 2003 and 2008. Compliance was measured as the medication possession ratio (MPR) during the first 12 months post-index. Cost and health care resource use were collected for the following 12 months.

RESULTS

Among the 38,234 women meeting the study inclusion criteria, 29.9 % were noncompliant (MPR <70 %). Younger age was associated with higher odds of compliance (OR [95 % CI] 1.22 [1.15-1.29] for ages 55-64 and 1.18 [1.12-1.24] for ages 65-74; reference age group ≥75 years). Rates of all-cause health care resource use were significantly higher in noncompliant subjects: 28.9 versus 23.0 % had inpatient admissions, 16.5 versus 13.0 % had emergency room visits, and 48.7 versus 43.3 % used outpatient services (P < 0.001 for all comparisons). The total mean (SD) all-cause cost per patient (excluding office visits) was €626 (2344) and €4178 (7854), respectively. The mean (SD) osteoporosis-related cost per patient (excluding office visits) was €572 (2085) and €754 (2857) for compliant and non-compliant subjects, respectively. The compliant subjects accrued significantly lower all-cause and OP-related cost than noncompliant subjects, regardless of whether the total cost or medical cost only was considered.

CONCLUSIONS

Approximately 30 % of Danish females aged 55 or older who take bisphosphonates are noncompliant. Noncompliance is significantly associated with increased health care resource use and cost.

Effects of long-term alendronate treatment on postmenopausal osteoporosis bone material properties

Raman microspectroscopic analysis of iliac crest from patients that were treated with alendronate (ALN) for 10 years revealed minimal, transient alterations in bone material properties confined to actively forming bone surfaces compared to patients that were on ALN for 5 years. These changes were not encountered in the bulk tissue.

INTRODUCTION

Alendronate (ALN) and other bisphosphonates (BPs) are the most widely prescribed therapy for postmenopausal osteoporosis. Despite their overall excellent safety record and efficacy in reducing fractures, questions have been raised regarding potential detrimental effects that may be related to prolonged bone turnover reduction, although no definite cause-effect relationship has been established to date. The purpose of the present study was to evaluate bone material properties in patients that were receiving ALN for 5 or 10 years.

METHODS

Raman microspectroscopic analysis was used to analyze iliac crest biopsies from postmenopausal women with osteoporosis who had been treated with ALN for 5 years and were then re-randomized to placebo (PBO, N = 14), 5 mg/day ALN (N = 10), or 10 mg/day ALN (N = 6) for another 5 years. The parameters monitored and expressed as a function of tissue age were (i) the mineral/matrix ratio (MM), (ii) the relative proteoglycan content (PG), (iii) the relative lipid content (LPD), (iv) the mineral maturity/crystallinity (MMC), and (v) the relative pyridinoline content (PYD).

RESULTS

The obtained data indicate that 10-year ALN use results in minimal, transient bone tissue composition changes compared to use for 5 years, confined to actively forming trabecular surfaces, implying potential differences in bone matrix maturation that nevertheless did not result in differences of these values in bulk tissue.

CONCLUSIONS

The data suggest that prolonged reduction in bone turnover during 10 years of therapy with ALN by itself is unlikely to be associated with adverse effects on bone material properties.

Quality of life in Japanese women with postmenopausal osteoporosis treated with raloxifene and vitamin D: post hoc analysis of a postmarketing study

OBJECTIVES

To assess the effect of active vitamin D3 on quality of life (QOL) and pain in raloxifene-treated Japanese women with postmenopausal osteoporosis.

RESEARCH DESIGN AND METHODS

This is a post hoc analysis of a previous prospective postmarketing observational study conducted without a comparator group. This study was conducted in 60 Japanese hospitals from September 2007 to February 2009. We compared changes from baseline in QOL and pain in patients receiving raloxifene plus active vitamin D3 with those in patients receiving raloxifene monotherapy at 8 and 24 weeks after treatment.

CLINICAL TRIAL REGISTRATION

Japan Pharmaceutical Information Center (JapicCTI-070465).

MAIN OUTCOME MEASURES

QOL and pain were assessed using Short Form-8 (SF-8), European Quality of Life Instrument 5 Dimensions (EQ-5D), Japanese Osteoporosis Quality of Life Questionnaire (JOQOL), visual analogue pain scales (VAS pain), and pain frequency scores.

RESULTS

A total of 506 patients were included in the post hoc analysis. Both raloxifene monotherapy (RLX, n = 354) and active vitamin D3 cotreatment (COMBI, n = 152) significantly improved QOL and reduced pain from the baseline at Week 8 and Week 24. The COMBI group had significantly greater improvements in JOQOL total score and activity of daily living (total) domain at Week 24 and last observation carried forward (LOCF) than the RLX group. The COMBI group also had significantly greater improvements in SF-8 domains of general health (at Week 8, Week 24, and LOCF), role physical (at Week 24 and LOCF), and mental health (at LOCF) than the RLX group. The COMBI group also had significantly greater reduction in VAS pain at LOCF than the RLX group (mean [SD]: RLX = -0.99 [2.72], COMBI = -1.54 [2.21], P = 0.042).

CONCLUSIONS

Active vitamin D3 supplementation to raloxifene treatment for 24 weeks may have additional benefits in improving QOL and relieving pain in Japanese women with postmenopausal osteoporosis.

Use of an educational support program to assist patients receiving injectable osteoporosis treatment: experience with teriparatide

OBJECTIVE

Low treatment adherence and persistence are important considerations in the management of chronic disorders such as osteoporosis, as they are linked to the reduced effectiveness of drug therapy. As teriparatide (Forsteo, Eli Lilly and Company, Alcobendas, Spain) is administered by subcutaneous injection using a customized delivery device for 24 months to reduce fracture risk in patients with osteoporosis, an educational support program was developed to assist patients with correctly administering the treatment.

METHODS

All patients in Spain can voluntarily participate in this ongoing program, which consists of up to 22 phone calls, by a qualified and licensed nurse trained in use of the delivery device, that are designed to improve patients' knowledge of, and to provide a reminder as to how to use, the device. Patients are also sent educational material regarding the delivery device and osteoporosis, and regularly receive needles suitable for the device. This study presents persistence data for all 23,069 patients registered in the program and prescribed teriparatide between September 2007 and June 2010.

RESULTS

Persistence in the program was 90.8% at 3 months, 83.5% at 6 months, 74.8% at 12 months, 68.5% at 18 months, and 64.1% at 24 months. Patient satisfaction with the educational support program was high at all assessment times, and patients generally found the delivery device easy to use.

CONCLUSIONS

These results show that patients from all provinces in Spain with severe osteoporosis receiving teriparatide and enrolled in an educational support program had high persistence and satisfaction with the program. However, no control group was included in these analyses and it is possible that selection bias occurred. It is suggested that patient-based strategies similar to this could be beneficial for all long-term treatments.

The role of counselling and other factors in compliance of postmenopausal osteoporotic patients to alendronate 70 therapy

INTRODUCTION

The aim of the study was to assess the role of patient counselling, nurse assistance and effects of biochemical examinations in adherence of women with postmenopausal osteoporosis to alendronate 70 administration over 12 months of therapy.

MATERIAL AND METHODS

Compliance and persistence to alendronate 70 therapy were assessed in a prospective study of 123 postmenopausal women, followed up for one year. The patients were divided into 4 groups (controls, counselled group, biochemical group and nurse assisted group) with monitoring every 6 months; in the nurse assisted group, additional phone contacts were made after 3 and 9 months of treatment. After 12 months, compliance and persistence were analysed. The medication possession ratio (MPR) was regarded as optimal when its value exceeded 80%.

RESULTS

The compliance to alendronate 70 therapy was 54.03% in the control group and the mean persistence with medication was 197 days. The MPR above 80% was observed in 37.5%, and, after 1 year, 43.75% of patients were found persistent with the therapy. In the remaining groups, both compliance and persistence were higher but not statistically significantly, compared to the control group. Neither patient's age, education, diet, nor physical activity influenced the compliance with prescribed therapy. The most common reason to discontinue therapy was either its side effects or smoking.

CONCLUSIONS

The obtained results suggest that better adherence with medical recommendations is observed in patients who receive additional attention, e.g. counselling, biochemical tests or nursing care. The critical elements for therapy discontinuation were side effects and smoking.

Quality of life in raloxifene-treated Japanese women with postmenopausal osteoporosis: a prospective, postmarketing observational study

OBJECTIVE

To assess changes in quality of life (QOL) and pain in raloxifene-treated Japanese women with postmenopausal osteoporosis.

RESEARCH DESIGN AND METHODS

This prospective, postmarketing observational study was conducted at 60 Japanese hospitals from September 2007 to February 2009 and included Japanese women with postmenopausal osteoporosis who were new to standard treatment with raloxifene (60 mg/day). Primary outcome measures (QOL and pain) were assessed using the Short Form-8 (SF-8), European Quality of Life Instrument (EQ-5D), osteoporosis-specific Japanese Osteoporosis Quality of Life Questionnaire (JOQOL), a visual analogue scale (VAS-pain), and a pain frequency survey. Assessments were performed at baseline and 8 (except JOQOL) and 24 weeks after first administration of raloxifene. Adverse drug reactions were recorded. Japan Pharmaceutical Information Center registration number: JapicCTI-070465.

RESULTS

A total of 506 participants, mean (±standard deviation [SD]) age = 70.7 ± 8.7 years, completed ≥1 follow-up assessment and were included in the analyses. All QOL scores increased from baseline during follow-up. All SF-8 domain scores increased significantly from baseline after 8 and 24 weeks (P < 0.001). Mean (±SD) EQ-5D scores increased significantly from baseline (0.70 ± 0.17) by 0.05 ± 0.15 after 8 weeks and 0.07 ± 0.17 after 24 weeks (P < 0.001). The mean (±SD) total JOQOL score increased significantly from baseline (66.8 ± 16.5) by 3.8 ± 11.3 after 24 weeks (P < 0.001). The percentage of participants with a ≥20 mm reduction in VAS-pain was 32.6% (120/368) and 39.5% (115/291) after 8 and 24 weeks, respectively. The frequency of pain reported by participants decreased after 8 and 24 weeks. Forty adverse drug reactions were reported by 34 participants.

LIMITATIONS

Limitations include the lack of a control group, the possibility of the changes being due to the natural disease course, and potential selection bias.

CONCLUSIONS

Our findings suggest that standard treatment with raloxifene improves QOL and relieves pain in Japanese women with postmenopausal osteoporosis in a real-world clinical setting.

Structural equation modeling of the proximal-distal continuum of adherence drivers

OBJECTIVES

Nonadherence to prescription medications has been shown to be significantly influenced by three key medication-specific beliefs: patients' perceived need for the prescribed medication, their concerns about the prescribed medication, and perceived medication affordability. Structural equation modeling was used to test the predictors of these three proximal determinants of medication adherence using the proximal-distal continuum of adherence drivers as the organizing conceptual framework.

METHODS

In Spring 2008, survey participants were selected from the Harris Interactive Chronic Illness Panel, an internet-based panel of hundreds of thousands of adults with chronic disease. Respondents were eligible for the survey if they were aged 40 years and older, resided in the US, and reported having at least one of six chronic diseases: asthma, diabetes, hyperlipidemia, hypertension, osteoporosis, or other cardiovascular disease. A final sample size of 1072 was achieved. The proximal medication beliefs were measured by three multi-item scales: perceived need for medications, perceived medication concerns, and perceived medication affordability. The intermediate sociomedical beliefs and skills included four multi-item scales: perceived disease severity, knowledge about the prescribed medication, perceived immunity to side effects, and perceived value of nutraceuticals. Generic health beliefs and skills consisted of patient engagement in their care, health information-seeking tendencies, internal health locus of control, a single-item measure of self-rated health, and general mental health. Structural equation modeling was used to model proximal-distal continuum of adherence drivers.

RESULTS

The average age was 58 years (range = 40-90 years), and 65% were female and 89% were white. Forty-one percent had at least a four-year college education, and just under half (45%) had an annual income of $50,000 or more. Hypertension and hyperlipidemia were each reported by about a quarter of respondents (24% and 23%, respectively). A smaller percentage of respondents had osteoporosis (17%), diabetes (15%), asthma (13%), or other cardiovascular disease (8%). Three independent variables were significantly associated with the three proximal adherence drivers: perceived disease severity, knowledge about the medication, and perceived value of nutraceuticals. Both perceived immunity to side effects and patient engagement was significantly associated with perceived need for medications and perceived medication concerns.

CONCLUSION

Testing the proximal-distal continuum of adherence drivers shed light on specific areas where adherence dialogue and enhancement should focus. Our results can help to inform the design of future adherence interventions as well as the content of patient education materials and adherence reminder letters. For long-term medication adherence, patients need to autonomously and intrinsically commit to therapy and that, in turn, is more likely to occur if they are both informed (disease and medication knowledge and rationale, disease severity, consequences of nonadherence, and side effects) and motivated (engaged in their care, perceive a need for medication, and believe the benefits outweigh the risks).

Protective effect of Sideritis euboea extract on bone mineral density and strength of ovariectomized rats

OBJECTIVE

The aim of this study was to investigate the potential protective effect of Sideritis euboea extract (SID), commonly consumed as "mountain tea," on bone mineral density (BMD) and the strength of the ovariectomized (OVX) rat model of osteoporosis.

METHODS

Thirty-two 10-month-old Wistar rats were separated into controls (sham operated), OVX, and OVX plus SID in their drinking water (dose, 330 mg/kg body weight per day), starting immediately after OVX for 6 months. Tibial BMD at baseline and at 3 and 6 months post-OVX, three-point-bending of the femur, and body and uterine weight at the study end were examined.

RESULTS

BMD percentage change from baseline of the whole tibia was similar in control and OVX + SID rats at 3 months (-3.02% vs -4.67%, P = not significant), revealing a strong osteoprotective effect. At 6 months, the corresponding changes were -6.02% versus -14.37%, P < 0.05, indicating a greater bone loss in treated rats, albeit significantly less than the OVX change (-20.46%; OVX vs OVX + SID, P < 0.05). The proximal (metaphyseal) tibial BMD percentage change from baseline to 3 and 6 months between the OVX and OVX + SID groups (-26.47% vs -15.57% and -31.22% vs -16.57%, respectively) was statistically significant, demonstrating that SID preserved the proximal tibial BMD of the OVX + SID group significantly. Three-point-bending showed a significant increase in the treated compared with the OVX groups. Body and uterine weights were similar in the OVX and treated groups.

CONCLUSIONS

SID significantly protected tibial bone loss and improved femoral biomechanical strength in OVX + SID rats compared with OVX rats.

Predictors of patients' perceived need for medication to prevent fracture

BACKGROUND

Adherence with medications to prevent fractures is suboptimal. Patients' perceived need for medication is an important predictor of medication-use behavior.

OBJECTIVE

Estimate the associations of patients' perceived need of medication for fracture prevention with objective indicators of fracture risk, patients' concerns about medications, and the quality of the patient-physician relationship.

RESEARCH DESIGN

Cross-sectional medical record review and mailed survey. A multivariate path model was used to estimate the associations of predictor variables with perceived need for fracture prevention medication.

SUBJECTS

A total of 1155 individuals were prescribed an oral bisphosphonate medication between January 1, 2006 and March 31, 2007 at a large urban multispecialty clinic in the United States.

RESULTS

Trust in the prescribing physician, prevalent vertebral fracture on spine imaging, patients' self-reported susceptibility to and perceived severity of fractures, and medication concerns were independently associated with perceived need for medication. Bone mineral density and fracture history were only weakly associated with perceived need for medication. Trust in the physician was associated with perceived severity of fractures but not with self-reported susceptibility to fractures. Patients' perceptions that their physician communicates openly with them and their satisfaction with their physician's decision-making style are strongly associated with their trust in that physician.

CONCLUSIONS

Documenting prevalent vertebral fracture may influence patients' perceived need for fracture prevention medication. Patients' trust in their physicians influences perceived need for fracture prevention medication. Patients' perceptions of open physician communication and their satisfaction with their physician's decision-making style are indirectly associated with perceived need for fracture prevention medication.

Adherence and persistence in patients with postmenopausal osteoporosis treated with raloxifene

OBJECTIVE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Medication adherence: a review of pharmacy education, research, practice and policy in Finland

AIMS

To describe pharmacy education, research, practice and policy related to medication adherence in Finland since the year 2000.

METHODS

The three universities that provide pharmacy education (Åbo Akademi, University of Eastern Finland, and University of Helsinki) completed a structured pro-forma questionnaire regarding education related to medication adherence. A MEDLINE and EMBASE literature search was performed to identify English language peer-reviewed research that reported medication compliance, adherence or persistence. The Ministry of Social Affairs and Health was invited to nominate policies and documents related to medication adherence. A narrative review of medication counselling practices and professional service delivery through Finnish community pharmacies was undertaken.

RESULTS

Medication adherence was a theme integrated into obligatory and elective courses for bachelors and masters degree students. The literature search identified 33 English language peer-reviewed research articles reporting medication compliance, adherence or persistence published since the year 2000. Policy documents of the Ministry of Social Affairs and Health recognise that poor medication adherence may lead to suboptimal treatment outcomes, and encourage patient participation in treatment decision making. Adherence practice in Finnish pharmacies has been strongly linked to the development of medication counselling services.

CONCLUSIONS

Adherence research and education has focused on understanding and addressing the contextual factors that contribute to medication nonadherence. Adherence practice in community pharmacies has tended to focus on medication counselling and programs specific to particular disease states. Medication adherence is a topic that is integrated into courses for bachelor's and master's level pharmacy students in Finland.

The impact of osteoporosis medication beliefs and side-effect experiences on non-adherence to oral bisphosphonates

OBJECTIVE

Non-adherence to oral bisphosphonate medications is a pervasive problem that blunts their potential to prevent fractures. Using multivariate modeling, we assessed the unique contribution of six classes of variables as drivers of non-adherence to bisphosphonates: (1) beliefs about osteoporosis and its prescription drug treatment, (2) ratings of the affordability of the prescription osteoporosis medications, (3) evaluations of the convenience of the bisphosphonate dosing frequency, (4) reports of troublesome side effects, (5) ratings of aspects of the bisphosphonate dosing regimen, and (6) risk factors for fracture. These categories of predictor variables were selected for investigation because they have been suggested by clinical-trial, survey, and observational studies in osteoporosis as reasons for non-adherence among patients taking prescription osteoporosis therapy.

METHODS

Women aged 45 or older who filled a prescription for an oral bisphosphonate in January or February of 2006 were identified through a dispensing database of 3300 US retail pharmacies. Subjects received a mailed pre-notification letter from the retail pharmacy chain informing them that someone would be calling them to invite them to participate in a telephone survey about osteoporosis medications. Trained interviewers used a standardized telephone script to recruit patients. Our definition of adherence was provisionally based on database records across a 7-month period and then cross-validated using patient self-report during the telephone recruitment. We measured beliefs regarding bisphosphonate effectiveness and safety, osteoporosis health concerns, concerns regarding drug costs, dosing frequency convenience, and experienced side effects using multi-item scales. Data were collected by telephone interview. Bivariate analyses were conducted using chi(2) and t-tests, and multivariate analyses were conducted using logistic regression.

RESULTS

Of the 3274 women contacted for study participation, 1092 (33%) completed the interview and 1015 had analyzable data. Multivariate analyses showed that those most symptomatic in terms of side effects and those with the most skeptical beliefs in drug effectiveness and drug safety had odds ratios for non-adherence of 6.78 (95% CI 4.67-9.86), 5.70 (95% CI 3.65-8.92), and 2.26 (95% CI 1.49-3.42), respect ively. In multivariate models, osteoporosis health concerns, dosing frequency convenience, and concerns regarding medication costs were not statistically associated with non-adherence to bisphosphonate therapy.

CONCLUSIONS

The experience of troublesome side effects and patient beliefs regarding the effectiveness and safety of oral bisphosphonate medications prescribed for them are strongly associated with bisphosphonate non-adherence. Improving adherence to oral bisphosphonates may require providers to solicit and address patients' medication beliefs and to proactively address side effects. Limitations of our study include: (1) the study sample is not likely to be a national random sample of bisphosphonate users, and (2) some evidence of non-response bias was observed.