Elsevier

Bone

Volume 38, Issue 4, Supplement 1, April 2006, Pages S2-S6
Bone

Adherence, patient preference and dosing frequency: Understanding the relationship

https://doi.org/10.1016/j.bone.2006.01.150Get rights and content

Abstract

Adherence to treatment among patients with chronic diseases is currently suboptimal. Poor adherence leads to reduced clinical benefit, a raised incidence of secondary complications and therefore increased healthcare costs. For patients with osteoporosis, long-term adherence to therapy is further complicated by the asymptomatic nature of the disease and the lack of options for patient self-monitoring. Bone densitometry and biochemical markers of bone turnover are assessments that could be used by physicians to provide feedback to patients on the effectiveness of medication. However, these feedback systems are costly and not readily available.

Oral bisphosphonates are currently the first-line therapy for postmenopausal osteoporosis. However, they are associated with stringent dosing procedures, and some patients may experience upper gastrointestinal side-effects following administration. Alarmingly, approximately 50% of patients discontinue daily bisphosphonate therapy within 1 year, which negatively impacts upon treatment outcomes, leading to a reduced antifracture effect. Thus, there is a need for an effective therapy that enhances patient adherence. The impact of reducing bisphosphonate dosing frequency on therapeutic adherence has been documented in several studies. Data have shown that, although weekly dosing improves adherence compared with daily administration, levels are still suboptimal.

Results from two recent studies that have assessed patient preference for a once-monthly compared with a weekly dosing schedule have demonstrated that patients prefer a monthly regimen (67–71%). Their reasons for preferring once-monthly dosing were that it would fit better with their lifestyle (49–77%) and would be more convenient (75%).

A novel once-monthly bisphosphonate regimen, such as the ibandronate regimen, may therefore help patients to follow dosing guidelines and encourage them to stay on therapy longer, thereby improving overall therapy effectiveness.

Introduction

Poor therapeutic adherence among patients suffering from chronic asymptomatic disease is a major issue facing physicians today [1]. Up to 50% of patients with chronic disease, such as hypertension, depression and asthma discontinue medication, with the rate rising in different therapeutic areas (up to 70% of patients prescribed preventive asthma medication stop treatment) and different countries (51% of patients in the USA continue with antihypertensives compared with 26% in the Seychelles). Poor adherence is considered to be ‘the primary reason for suboptimal clinical benefit’ of therapy [1]. Since the primary objective of treatment is not met, patients may experience complications. Furthermore, patients may experience reduced quality of life, which, in turn, leads to greater healthcare costs. Therefore, addressing poor adherence could potentially benefit both patients and society [1].

Section snippets

Therapeutic adherence

In general terms, adherence is ‘the extent to which a person's behavior—taking medication, following a diet, and/or executing lifestyle changes—corresponds with agreed recommendations from a health care provider’ [1]. Therapeutic adherence is a summary term determined by persistence and compliance of medication intake. Persistence describes the length of time a patient continues taking medication and is measured as the time from treatment initiation to treatment completion or discontinuation.

Adherence with therapy for the treatment of osteoporosis

Osteoporosis is a chronic, asymptomatic condition characterized by low bone mass and an increased fragility for fracture [3]. Patients often experience few clinical symptoms prior to fracture and do not perceive the need for treatment [4]. Data from a study evaluating adherence to bisphosphonate therapy show that the probability of continuing daily oral treatment is approximately 50% at 1 year [5]. Even when diagnosed, patients may not perceive any direct benefit from taking medication as they

Impact of poor adherence with bisphosphonates on treatment outcomes

Suboptimal therapeutic adherence with oral bisphosphonates negatively impacts upon treatment outcomes. Compliance with risedronate and its influence on biochemical markers of bone turnover was assessed in a sub-analysis of patients from the IMPACT database (n = 2302) [20]. After 22 weeks of treatment, approximately 60% of compliant patients had a >50% decrease from baseline in serum C-telopeptide of the α-chain of type I collagen, compared with 20% of non-compliant patients. A second study

Can reducing dosing frequency improve therapeutic adherence?

Since it is important for patients receiving bisphosphonates to remain on treatment in order to obtain maximum clinical benefit, any factors that could increase adherence are worthy of investigation. A report from the Surgeon General raises the question as to whether the currently available doses and schedules of osteoporosis medication are the most effective for encouraging adherence and therefore reducing fractures in the ‘real-world’ setting [23]. The report also asks whether increasing the

Influence of patient preference on therapeutic adherence

Patient's preferences for daily or weekly bisphosphonate therapy have been evaluated in a prospective, open-label studies [27], [28]. Four hundred and six postmenopausal women with osteoporosis were randomized to receive daily and weekly alendronate for 4 weeks per regimen using a crossover design. A total of 396 participants received both regimens and completed a preference questionnaire. Of the 364 (92%) women who expressed a preference, a significant number of patients (over 80%) expressed a

Discussion

Poor adherence is a common cause of reduced patient benefit from therapies used in the ‘real-world’ setting compared with the benefits demonstrated in clinical trials. Inadequate therapeutic adherence to oral bisphosphonates in the treatment of osteoporosis compromises therapeutic outcomes, resulting in lower BMD gains, reduced effects on bone turnover and subsequently a lower antifracture effect. It has been shown that improving compliance and persistence enhances patient outcomes. Therefore,

References (30)

  • B. Hamilton et al.

    Tolerability and compliance with risedronate in clinical practice

    Osteoporos. Int.

    (2003)
  • C.S. Pickney et al.

    Correlation between patient recall of bone densitometry results and subsequent treatment adherence

    Osteoporos Int.

    (2005)
  • J. Reginster et al.

    Randomized trial of the effects of risedronate on vertebral fractures in women with established postmenopausal osteoporosis. Vertebral Efficacy with Risedronate Therapy (VERT) Study Group

    Osteoporos. Int.

    (2000)
  • C.H. Chesnut et al.

    Effects of oral ibandronate administered daily or intermittently on fracture risk in postmenopausal osteoporosis

    J. Bone Miner. Res.

    (2004)
  • S.R. Cummings et al.

    Effect of alendronate on risk of fracture in women with low bone density but without vertebral fractures: results from the Fracture Intervention Trial

    JAMA

    (1998)
  • Cited by (102)

    • Involving patients, the insured and the general public in healthcare decision making

      2016, Zeitschrift fur Evidenz, Fortbildung und Qualitat im Gesundheitswesen
    • Effects of denosumab on bone mineral density and renal function in postmenopausal women transitioning from raloxifene

      2015, Tzu Chi Medical Journal
      Citation Excerpt :

      Different medications are given orally, subcutaneously, or intravenously [5–7]. Several oral drugs used in the treatment of postmenopausal osteoporosis, which have all shown efficacy in reducing fracture risk, are greatly affected by adherence to treatment, a critical issue in the management of osteoporosis [8,9]. Many patients do not perceive the need for treatment of osteoporosis until they experience the first fracture [10].

    View all citing articles on Scopus
    View full text