March 22, 2020

Why is adherence to Osteoporosis medicines so difficult?


Looking at why adherence to Osteoporosis medicines is so difficult?


One of the biggest problems facing those at the frontline of managing and maintaining those with and at risk of osteoporosis, is ensuring that people adhere to their medication regimes – that is taking their medicines as prescribed.


Despite the known long-term risks of painful fracture, sometimes necessitating surgical remedy and prolonged rehabilitation, many people still fail to take the right medication, at the right time, in the right way, and for the right duration. Why should this be?


There are several well described treatments which are effective in reducing fracture risk, yet similar to other chronic disease which do not present patients with symptoms until there is a significant ‘event’, adherence to therapies is poor.


Commonly cited reasons for poor adherence include concerns around potential side effects, bad tasting medications or ones which may cause mild to moderate nausea. Difficulty complying with medicines regimes, forgetfulness, and resistance to taking medicines for a disease which is causing no apparent outward symptoms are mentioned frequently.


Despite a wider range of treatments for osteoporosis with differing methods of administration, different frequencies at which they need to be taken, and different formulations, adherence across all osteoporosis therapies worldwide is poor. Some studies cite overall adherence to osteoporosis therapies as low as 40-70%.


Patient surveys tend to report better levels of self-reported adherence than pill count and objective data suggests. However, it is difficult for objective data sources to assess whether or not patients are actually taking the medication in the correct way, or what the barriers to adherence may be across different patient groups by say age, or socio-economic background.


Patient ‘drop-off’ or persistence is also low, with only one half of all patients continuing  with their medication (regardless of the adherence rate) beyond 6 months. Re-initiation rates for people taking bisphosphonates, a common treatment, for example, are between 30% and 50% within 2 years of a break.


In paying countries, although it may be expected that cost of medication and access to treatment is a factor, it has not been found to be significant. Many generic, ‘non-branded’ treatments are available which may play a part in this.


For many, the potential for a medicine to cause side-effects, rather than actual experience of side-effects, is a significant impediment to good medicines regimes. In particular, patients who may have experienced side effects of other (non-related) medicines in the past are less likely to adhere.


Paradoxically, perceived lack of benefit, particularly if a patient develops a fracture while taking medication, is also a common reason for non-adherence. Patients are unwilling to take a medication for asymptomatic disease where there is lack of confidence that the medication is having a positive benefit. However, those who are concerned about the potential consequences of a fracture (inability to wok, loss of income, reduced travel etc) may be more likely to follow medicines regimes, if they are given appropriate information in advance.


Some groups of patients who may feel otherwise healthy prefer a ‘natural’ treatment, relying on Calcium or Vitamin D supplements with simple dosing. This can sometimes be in stark contrast to the stringent and/or complicated demands of traditional medicines. Unsurprisingly, medicines which require fewer interactions tend to have better adherence rates, as do those which have fewer potential gastro-intestinal side effects such as vomiting, nausea or diarrhoea.


Aggregated data tends to be less useful in ability to discriminate between compliant, and non-compliant persons. It has been suggested that prior compliance to other medications for non-associated conditions was a high predictor of osteoporosis compliance.


Talking Medicines believe that identifying cohorts of patients by examining their real world behaviours and medication histories during and prior to osteoporosis care may create valuable and  beneficial insights, including the opportunity to develop bespoke support pathways to better adherence. The Medsmart® Community will play no small part in helping us to understand this important area, helping others like themselves through the power of the Patient Voice.


**8. Kothawala P, Badamgarav E, Ryu S, Miller RM, Halbert RJ. Systematic review and meta-analysis of real-world adherence to drug therapy for osteoporosis. Mayo Clinic proceedings. 2007 Dec;82(12):1493–501. This meta-analysis of osteoporosis treatment adherence from 1990–2006 combines results from various studies to provide summary results pertaining to compliance, persistence and adherence.


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