Medical Therapy for Osteoporosis and Approaches to Improving Adherence
Education, Reminders, Phone-Based
Improving patient knowledge of osteoporosis, especially with education using visual aids, may help with improving adherence [47]. In a randomized controlled trial at a single health management organization, an interactive voice response phone call plus a letter 1 week later increased the rate of obtaining a prescribed oral bisphosphonate in the intervention group (48.8% vs. 30.5% control; OR 2.3, 95% CI 1.34–3.94) when adjusted for age, sex, prior BMD, and fracture [77]. Use of an encounter decision aid also improved knowledge of osteoporosis medication options and led to a doubling of medication prescription attainment. However, adherence at 6 months was not improved [78].
Pill reminders in the form of text messages, paging systems on medication devices, and alarm beeps have been studied in patients with chronic diseases, and these technologies could be utilized for osteoporosis treatment [79–81]. A study of smart phone applications showed that many apps help with adherence, especially in noncompliant patients [82]. The researchers reported that of apps studied, MyMedSchedule, MyMeds, and RxmindMe were among the most highly rated due to their ease of use and enhanced functions. Solomon et all studied the effectiveness of a telephone-based counseling program using motivational interviewing in a large randomized study. They found no significant improvement in adherence to an osteoporosis regimen with the telephonic motivational interview compared to mailed educational materials (control group) (P = 0.07) [83]. In a 12-month multicenter, prospective randomized study, Bianchi et al examined the effectiveness of an intervention of reminders or reminders plus phone calls and meetings at the referral center in postmenopausal women initiating an oral osteoporosis prescription. No significant difference was seen in adherence at 12 months compared to standard care [84]. Adherence among the entire cohort, however, was very high [84]
Pharmacist-Based
The role of pharmacists in the treatment of chronic diseases, including osteoporosis, has been studied and shown to be cost-effective. In a study by van Boven et al, an algorithm was designed to detect patients with nonadherence and then tailor an intervention that consisted of structured counseling and active monitoring by pharmacists in initial and continuous phases [85]. This effort-intensive intervention resulted in reduced discontinuation of bisphosphonates after 12 months (reduction from 31.7% to 16.2% at 12 months) [85]. Despite the effort required, findings from the study support overall cost-effectiveness of this intervention [85]. A randomized controlled study by Lai et al showed that pharmacists can play a role in improving medication adherence through counseling patients on the importance of adherence, side effects, and goals of therapy [86]. The same authors also showed that involvement of a clinical pharmacist in the care of patients helped to further improve patient knowledge of medications and osteoporosis treatments, resolve medication-related concerns, and improve overall quality of life [87]. Such pharmacist-led interventions would require pharmacists to understand their role and the potential for drug holidays in the course of osteoporosis treatments and not mislabel patients as nonadherent when in fact purposefully holding osteoporosis medications [88].
Conclusion
Osteoporosis is a growing problem with increasing numbers of patients at risk for osteoporosis and related fractures. Currently available osteoporosis medications have shown clear benefit in reducing fracture risk; however, adherence to these therapies is required to obtain benefit. Unfortunately, osteoporosis medications have several limitations to full compliance, particularly the oral treatment options, including known possible side effects acutely and chronically, potential/feared side effects, irregular dosing intervals, complicated dosing instructions, and absence of an immediate recognizable benefit/effect. Improving adherence is complex [89] and tailoring to individual patients is of importance. Successful techniques for improving adherence may include a focus on physician-patient communication, use of the less frequently dosed medications, various medication reminders, use of available technology, and use of pharmacists for patient counseling and monitoring. Recognition of this common problem by clinicians is of utmost importance.
Corresponding author: Amy H. Warriner, MD, The University of Alabama at Birmingham, Division of Endocrinology, Diabetes and Metabolism, 702 Faculty Office Tower, 510 20th Street South, Birmingham, AL 35294, warriner@uab.edu.
Financial disclosures: None.
