| The significant
morbidity and mortality associated with osteoporosis
(OP) underscore the importance of compliance with
the therapeutic regimen. Yet noncompliance with
OP medications is common. Factors contributing
to noncompliance in persons with OP include the
asymptomatic nature of the disease, prolonged
duration of therapy, drug-associated adverse effects,
elderly age, and personal beliefs and fears.
The 3 leading causes of noncompliance are failure
to fill the prescription, incorrect use of medication,
and premature abandonment of therapy. Osteoporosis
(OP), a reduction in bone mass leading to bone
fragility, currently affects approximately 75
million persons in Europe, the United States,
and Japan, and its incidence is increasing as
the population ages1. OP-related fracture is a
common cause of prolonged hospitalization and
rehabilitation and is a significant cause of mortality
among the elderly. Noncompliance with OP treatments
therefore poses severe consequences for both the
patient and society.
When choosing from among the available OP treatments,
the physician is faced with a barrage of medication-
and patient-related considerations.
The ultimate goal is to choose an approach that
the patient can live with long-term, because the
best medication in the world is only as good as
the patient's willingness and ability to comply
with therapy.
REASONS FOR NONCOMPLIANCE:
General:
Compliance with medications for chronic conditions,
including OP, is notoriously poor for several
reasons 2, 3. Like many chronic diseases, OP is
asymptomatic. Therefore, the patient perceives
no immediate benefit from taking the prescribed
medication. Furthermore, OP treatment must continue
for years. Discontinuation of hormone replacement
therapy (HRT) results in accelerated bone loss.
Medication-related adverse effects are another
impediment.
Disease specific:
Certain factors specific to OP contribute to noncompliance.
Heading the list is an overall lack of appreciation
of the seriousness of the problem 4 and that OP
is silent until the time of fracture. Only a third
of patients with vertebral fracture are symptomatic.
However, within 1 year of vertebral fracture,
20% of patients will have a second fracture.5
Many persons accept OP as an inevitable consequence
of aging and believe that physical decline is
unavoidable. This set of personal beliefs undermines
attempts at effective intervention.
TREATMENT-RELATED FACTORS
Correct use of medication encompasses several
steps:
* Obtaining the prescription.
* Taking the medication appropriately (correct
dosage, frequency, and route of administration).
* Continuing the medication for the prescribed
duration.
These steps are often grouped under the general
heading of compliance, which is defined as the
extent to which a patient's behavior coincides
with medical care or advice 2. The physician may
be able to improve outcome by identifying where
the patient is noncompliant.
Taking the drug:
Persons with OP are often poorly compliant from
the first step: obtaining the medication. In a
study of 127 patients who were prescribed HRT
following bone mineral density (BMD) assessments,
27 (21%) did not fill their prescription. Of these
patients, 11 (41%) cited concern over side effects
or breast cancer as their reason 6.
Even when patients start treatment, they often
take the drug incorrectly. Bisphosphonates, such
as alendronate or risedronate, come with complex
dosing instructions, such as taking the medicine
with a full glass of water or with no milk, juice,
or coffee at least 30 minutes before breakfast
and remaining upright for at least 30 minutes.
Physician-patient relationship:
Improving relationships:
Effective communication between the physician
and patient improves compliances, patient satisfaction,
and clinical outcome 2, 7, 8. As part of this,
physicians can tailor therapy to the patient's
lifestyle 9 and actively involve the patient in
clinical discussions and decisions. All of this
builds trust, which significantly benefits compliance
and satisfaction with treatment.
Before discussing therapy, we review clinical
data concerning the patient's individual risk
of OP and explain the potentially severe consequences
of this disorder. We also explain how BMD measurements
predict bone strength: fracture risk approximately
doubles for every SD change in BMD. BMD measurements
thus are an objective means for showing the patient's
exact position in the OP-osteopenia-normal spectrum
and clarifying her personal risk of OP. One study
showed that results of BMD testing significantly
influence a woman's decision to start HRT: those
with the lowest BMD measurements are significantly
more likely to fill
their prescription for HRT.
Considerations in the elderly:
Elderly persons with cognitive or memory deficits
are most likely to benefit from a medication with
a simple, relatively infrequent dosing regimen
that can be tied in with daily reminders or cues.
Physical limitations are another consideration.
For example, persons who have difficulty remaining
upright are poor candidates for alendronate. In
addition, persons who have difficulty swallowing
or remaining upright are poor candidates for bisphosphonate.
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