Osteoporosis Medications: Are your Patients Really Taking Them?
Osteoporosis Medications: Are your Patients Really Taking Them?
Abstract & Commentary
By Eileen C. West, MD, Director of Primary Care Women's Health, Clinical Assistant Professor of Internal Medicine, University of Oklahoma School of Medicine, Oklahoma City. Dr. West reports no financial relationship to this field of study.
Synopsis: A 6-year retrospective study shows that 45% of Medicare patients with state-funded drug benefits who initiate a medication for osteoporosis do not continue to take it as prescribed one year later and 52% are no longer compliant 5-years later.
Source: Solomon DH, et al. Compliance with osteoporosis medications. Arch Int Med. 2005;165:2414-2419.
Compliance with medications for medical conditions which are not currently causing symptoms is notoriously low. Studies looking at high blood pressure and cholesterol medication use have given similar results: only 40-60% of patients in large community-based studies continue to take medications one year after initiation.
To date, research on compliance with osteoporosis medications has shown that approximately 70% of women 45 years or older who have undergone bone mineral density testing continue to take medication as prescribed after one year. Compliance was determined by self report in a health maintenance organization setting.
In this study, the authors focus on an older, lower income population. They included all Medicare beneficiaries also eligible for a state-run drug benefits program in Pennsylvania in this retrospective cohort study from 1996-2002. Patients were initiating therapy and were required to pay a co-payment of $6 to $10 for the drug. The drugs included once daily bisphosphonates (alendronate, sodium, and risedronate), calcitonin, hormone therapy, and raloxifene hydrochloride.
There were 40,002 patients identified. Osteoporosis medication use was recorded for sequential 60-day periods, and the patients were followed until they died or lost eligibility for the drug benefit. Compliance was recorded as no days with medications, 1%- 33% of days, 34%-66% of days, and greater than 66% of days. Since those taking osteoporosis medication two-thirds of the time or greater have been shown to have improved bone mineral density, this cutoff was used to define compliance.
The average age of the group treated was 80 years. Most were white and female; 12% were residents of nursing homes. 19% had suffered a fracture of the hip, wrist, humerus, or spine. Each took, on average, 9 medications, and 38% had been in an acute care facility in the year prior to enrolling in the study.
After initiation of one of the osteoporosis study medications, the percentage of days covered decreased rapidly during the first year. At the end of the first year of treatment, 45.2% of patients had stopped filling the prescriptions. After 5 years, 52.1% were no longer taking them.
Who was most likely to continue to take medication after 5 years? Those who had a baseline and follow up bone density testing were much more likely to continue the drugs. Those who suffered a fracture at any point were more compliant, as well as those residing in nursing homes. Patient age played a role, with better compliance seen in the younger groups. Poor compliance was seen in those older than 85 years old. Compliance was best with raloxifene, followed by a bisphosphonate. Those taking calcitonin or hormone therapy were least compliant.
Commentary
As health care providers, we can make recommendations, but we can't guarantee that our patients will follow them. Based on this study, compliance with osteoporosis medications is low. One disadvantage to the study is that we have no information about why the drugs were discontinued. Cost, convenience, side effects, and lack of understanding of the importance of treatment and prevention have all been implicated. The effect of cost on compliance was not studied, but is likely to further decrease consistent use of these medications.
Drug therapy for osteoporosis is moving toward longer-acting formulations, and routes of delivery which can improve compliance. Many new agents are under study among drug classes already being used to prevent or treat osteoporosis. The manufacturer of the bisphosphonate ibandronate, now available in a monthly pill, is seeking FDA approval for treatment of osteoporosis for an intravenous dose administered every 2 to 3 months. New bisphosphonates that are in development—such as clodronate and minodronate—may need fewer doses, and come in different dosage forms. Parathyroid hormone (PTH), whose compliance was not studied because it was not available in 2002, is also being developed in non-injected forms, such as transdermal patches. Several new SERMS are under study including arzoxifene, bazedoxifene, lasofoxifene, and ospemifene. In addition, there are many new drug classes such as bisphosphonate esters (BPEs), cathepsin K inhibitors, insulin-like growth factor-1 (IGF-1) and integrin receptor inhibitors (also called disintegrins) which are under study. Applications of existing medications, such as the statins, are being evaluated for osteoporosis treatment and show potential for benefit. The next 5 years promise to be a time of change and development in the management of osteoporosis. Whether your patients will take the medications is another issue altogether.
A 6-year retrospective study shows that 45% of Medicare patients with state-funded drug benefits who initiate a medication for osteoporosis do not continue to take it as prescribed one year later and 52% are no longer compliant 5-years later.Subscribe Now for Access
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