Systematic Review and Meta-analysis of Real-World Adherence to Drug Therapy for Osteoporosis

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Mayo Clinic Proceedings (Impact Factor: 6.26). 01/2008; 82(12):1493-501. DOI: 10.1016/S0025-6196(11)61093-8
Source: PubMed


To quantify the adherence of patients to drug therapy for osteoporosis in real-world settings via a systematic review and meta-analysis of observational studies.
The PubMed and Cochrane databases were searched for English-language observational studies published from January 1, 1990, to February 15, 2006, that assessed patient adherence to drug therapy for osteoporosis using the following medical subject headings and keywords: drug therapy, medication adherence, medication persistence, medication possession ratio, patient compliance, and osteoporosis. Studies were stratified into 3 groups: persistence (how long a patient continues therapy), compliance (how correctly, in terms of dose and frequency, a patient takes the medication), and adherence (a combination of persistence and compliance). A random-effects model was used to pool results from the selected studies.
Twenty-four studies were included in the meta-analysis. The pooled database-derived persistence rate was 52% (95% confidence interval [CI], 44%-59%) for treatment lasting 1 to 6 months, 50% (95% CI, 37%-63%) for treatment lasting 7 to 12 months, 42% (95% CI, 20%-68%) for treatment lasting 13 to 24 months, returning to 52% (95% CI, 45%-58%) for treatment lasting more than 24 months. Pooled adherence rates decreased from 53% (95% CI, 52%-54%) for treatment lasting 1 to 6 months to 43% for treatment lasting 7 to 12 months (95% CI, 38%-49%) or 13 to 24 months (43%; 95% CI, 32%-54%). The pooled refill compliance estimate was 68% (95% CI, 63%-72%) for treatment lasting 7 to 12 months and 68% (95% CI, 67%-69%) for treatment lasting 13 to 24 months. The pooled self-reported compliance rate was 62% (95% CI, 48%-75%) for treatment lasting 1 to 6 months and 66% (95% CI, 45%-81%) for treatment lasting 7 to 12 months.
One-third to half of patients do not take their medication as directed. Nonadherence occurs shortly after treatment initiation. Terms and definitions need to be standardized to permit comparability of technologies designed to improve patient adherence. Prospective trials are needed to assess the relationship between adherence and patient outcomes.

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    • "Hence, the commonly used methods of measuring adherence, which classify patients as discontinued after a gap of at least 90 days even if they later restart the same therapy [11,12], or exclude patients if they switch to another anti-osteoporosis medication or different dosage [13,14], may underestimate overall treatment adherence and hinder understanding of the utilization of bisphosphonate therapy. For a study of the efficacy, effectiveness, and/or safety of a specific type, route, or dose of bisphosphonate (e.g., alendronate, risedronate, ibandronate), a narrow definition of discontinuation may be appropriate. "
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    ABSTRACT: Low adherence to bisphosphonate therapy is associated with increased fracture risk. Factors associated with discontinuation of osteoporosis medications have not been studied in-depth. This study assessed medication discontinuation and switching patterns among Medicare beneficiaries who were new users of bisphosphonates and evaluated factors possibly associated with discontinuation. We identified patients initiating bisphosphonate treatment using a 5% random sample of Medicare beneficiaries with at least 24 months of traditional fee-for-service and part D drug coverage from 2006 through 2009. We classified medication status at the end of follow-up as: continued original bisphosphonate, discontinued without switching or restarting, restarted the same drug after a treatment gap (>= 90 days), or switched to another anti-osteoporosis medication. We conducted logistic regression analyses to identify baseline characteristics associated with discontinuation and a case-crossover analysis to identify factors that precipitate discontinuation. Of 21,452 new users followed respectively for 12 months, 44% continued their original therapy, 36% discontinued without switching or restarting, 8% restarted the same drug after a gap greater than 90 days, and 11% switched to another anti-osteoporosis medication. Factors assessed during the 12-month period before initiation were weakly associated with discontinuation. Several Factors measured during follow-up were associated with discontinuation, including more physician visits, hospitalization, having a dual-energy X-ray absorptiometry test, higher Charlson comorbidity index scores, higher out-of-pocket drug payments, and upper gastrointestinal problems. Patterns were similar for 4,738 new users followed for 30 months. Among new bisphosphonates users, switching within and across drug classes and extended treatment gaps are common. Robust definitions and time-varying considerations should be considered to characterize medication discontinuation more accurately.
    BMC Musculoskeletal Disorders 04/2014; 15(1):112. DOI:10.1186/1471-2474-15-112 · 1.72 Impact Factor
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    • "Despite the availability of several treatment options for osteoporosis, adherence to anti-osteoporotic therapy in real-world practice is suboptimal and has generally been lower than in clinical trials. In a meta-analysis of 24 studies, 40-70% of osteoporotic patients were reported to be non-adherent [13]. Although male subjects at an advanced age often have osteoporosis and osteoporotic fractures, little is known about their exact adherence rates because researchers rarely include men in osteoporosis adherence studies, [14,15] or seldom report adherence rates separately or exclusively for men. "
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    ABSTRACT: To investigate adherence and patient-specific factors associated with poor compliance with osteoporosis regimens among men. In this retrospective chart review study, we collected data on male patients with osteoporosis treated in accordance with therapeutic recommendations. Adherence was determined by the compliance and persistence of those patients who had been dispensed an osteoporosis regimen after an index prescription. All osteoporosis regimens were considered equivalent for the purpose of investigating adherence. The prescriptions of 333 males met the inclusion criteria for data collection. The mean age was 68.6 +/- 10.4 years. The median medication possession ratio (MPR,%) at years 1 and 2 was 90.1% (interquartile range (IQR) 19--100) and 53.7% (IQR 10.4-100), respectively; 52.3% of male patients at year 1 and 37.5% at year 2 had good compliance (defined as a MPR>=80%). The 1- and 2-year persistence rates were 45.9% and 30.0%, respectively. Patient-specific factors associated with poor compliance (MPR < 80%) during year 1 were first prescriptions given by orthopedists (odds ratio (OR) = 2.67; 95% confidence interval (CI) = 1.58-4.53; adjusted OR = 2.30, 95% CI = 1.26-4.22, p = 0.007). Male patients with rheumatoid arthritis (RA) (OR = 0.22, 95% CI = 0.06-0.78, adjusted OR = 0.19, 95% CI = 0.04-0.81, p = 0.025) and baseline bone mineral density (BMD) measurements (OR = 0.52, 95% CI = 0.32-0.85; adjusted OR = 0.51; 95% CI = 0.28-0.93, p = 0.029) were less likely to have poor compliance. Adherence to osteoporosis regimens in males was suboptimal in our study. Poor compliance was more likely in prescription of the first anti-osteoporotic regimen by an orthopedist. Men with RA and BMD measurements before therapy had a lower risk of non-adherence. Healthcare professionals need to target patients with specific factors to improve adherence to osteoporotic regimens.
    BMC Musculoskeletal Disorders 09/2013; 14(1):276. DOI:10.1186/1471-2474-14-276 · 1.72 Impact Factor
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    • "These results are generally better than pharmacologic interventions aimed at treating osteoporosis. For example, a meta-analysis of 24 large observational studies found that adherence to drug therapies for osteoporosis ranged from 40% to 70% [64]. In addition, one must consider the potential side effects and costs associated with pharmacologic interventions. "
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    ABSTRACT: Background. Dropouts and compliance to exercise interventions targeting bone mineral density (BMD) in adults are not well established. The purpose of this study was to address that gap. Methods. Meta-analysis of randomized controlled exercise intervention trials in adults ≥18 years of age. The primary outcomes were dropouts in the exercise and control groups as well as compliance to the exercise interventions. A random-effects model was used to pool results. Moderator analyses were conducted using mixed-effects ANOVA-like models and metaregression. Statistical significance was set at P ≤ 0.05. Results. Thirty-six studies representing 3,297 participants (1,855 exercise, 1,442 control) were included. Dropout rates in the exercise and control groups averaged 20.9% (95% CI 16.7%-25.9%) and 15.9% (11.8%-21.1%) while compliance to exercise was 76.3% (71.7%-80.3%). For both exercise and control groups, greater dropout rates were associated with studies conducted in the USA versus other countries, females versus males, premenopausal versus postmenopausal women, younger versus older participants, longer studies (controls only), and high- versus moderate-intensity training (exercisers only). Greater compliance to exercise was associated with being female, home- or facility-based exercise versus both, and shorter studies. Conclusion. These findings provide important information for researchers and practitioners with respect to exercise programs targeting BMD in adults.
    Journal of Osteoporosis 06/2013; 2013(7):250423. DOI:10.1155/2013/250423
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