Breaking Barriers: Addressing Medication Adherence in Osteoporosis

Article:
Yeam, C.T., Chia, S., Tan, H.C.C. et al. A systematic review of factors affecting medication adherence among patients with osteoporosis. Osteoporos Int 29, 2623–2637 (2018). https://doi.org/10.1007/s00198-018-4759-3

This past week, I was doing the weekly inbox purge, going through the typical routine of reviewing patient messages, acknowledging results, and ordering future tests.  Part of this task requires looking at expired medications for my osteoporosis patients.   Inevitably, every month, there are a few patients with the message, “Unable to contact the patient to continue treatment” or “Patient no longer interested in treatment.”  If you have treated osteoporosis or post-fracture patients long enough, you will have patients who do not adhere to the treatment plan.  Maybe they fall off after 12 months, maybe 3 years.  There are many reasons for this.  Some reasons are valid. Perhaps the patient is getting care elsewhere.  Maybe they had to discontinue the medication due to side effects. Possibly, they have since passed.  When I see these messages, I always reflect on my initial visits with the patient.  That first visit discussing treatment is always long.  It primarily entails educating the patient on the importance of therapy after a fracture or preventing fractures.  When I have patients who fall off on their treatment, I always ask myself if there is something I can do differently.  Do I need to change my tactics so that my patients have everything they need to want to continue with treatment?  I am reviewing an article about medication adherence and its effects this month.   This meta-analysis by Chen examined multiple articles on adherence. It quotes a range of adherence rates, from 12% to 95%. Chen identified five key domains that adherence factors fall into. Each domain presents unique challenges that practitioners can address to serve their patients better. 

1.      Condition-Related Factors

Patients with many medical comorbidities have difficulties with adherence to osteoporosis medications.  Especially patients who experience conditions like depression and dementia.  Patients who have many medical comorbidities spend many hours at medical appointments.  Post-fracture and osteoporosis visits tend to be every 6 months or a year.  It is easy to get these visits lost among their many other medical appointments.   Patients with many comorbidities tend to deal with polypharmacy.  This also contributes to issues with adherence.  Patients experiencing polypharmacy are 12% more likely to face challenges with medication adherence. 

2.      Patient-Related Factors

Advanced age, lower education levels, and osteoporosis misconceptions can be expected in this patient population. Getting patients to buy into long-term treatment can be difficult if they are skeptical.   Osteoporosis can be difficult for some patients to grasp.  Osteoporosis doesn’t hurt.  You cannot feel if your bones are soft.  There is also a long-standing dogma that people get old; they fall, they break.  Some patients continue to believe this is the normal progression of life and that we can do nothing about it.   Misconceptions about osteoporosis were associated with 11% of studies in the article.  In my practice, I continue to work hard at the education piece. I want my patients to feel like they are a part of the decision-making process because they are.  Patients who take ownership of their condition tend to adhere better.

3.      Therapy-Related Factors

Dosing frequencies can affect patients’ adherence. Oral bisphosphonates require patients to remember to take their medication at weekly or monthly intervals. Injectable medications must be scheduled for a month or six months. Remembering to make these appointments can be cumbersome for the patient. Daily injections for PTH analogs can become frustrating over time. Remembering these intervals can be difficult. Working to simplify these regimens will go a long way.

Side effects of these medications also play a factor. We have all had patients who have a worsening of their GERD or other gastric issues with oral bisphosphonates.  Or patients that experience a hypersensitivity reaction to infusion zoledronic acid.  Patients who were already on the fence about treatment will easily find reasons to quit treatment after these issues arise.  Side effect management, including discussing side effects and their likelihood at the beginning of therapy, allows the patient to prepare mentally.  I have found that adherence increases in my practice if we discuss this possibility from the beginning. We have all had patients who were reluctant to start medication think every visceral symptom they experienced after the start of treatment was due to their new osteoporosis medication.  Discussing black box warnings of medications at the beginning of therapy will improve adherence.  There is much on the internet about the likelihood of MRONJ and AFF.  Discussing the actual data and what we know about these issues upfront helps the patient.  Stating their rarity and what we know about the condition tends to put patients at ease. 

4.      Health System Factors

Care under non-specialists is linked to adherence. Patients who are not “Boneheads” are less comfortable with these medications. They are typically only comfortable with oral bisphosphonates. Once they fail or patients experience a side effect, treatment is stopped, and everyone proceeds with their fingers crossed in hopes that gravity affects these patients differently than everyone else. These patients may never be appropriately treated if they do not have access to specialists in their area.   Patient support programs can help with some of this by linking patients with specialists.  These programs tend to only be in larger communities.  Smaller and more rural communities may have fewer of these available.  This is an excellent role for FLS programs and interdisciplinary care models to make a meaningful difference for these patients.  Patients treated by non-specialists have a 30% lower adherence rate than patients treated under osteoporosis specialists. 

5.      Socio-Economic Factors

The high cost of some of these medications and the access to patients via their healthcare coverage can also affect adherence.  Available generic medications can help this problem.  However, the availability of anabolic medication in the generics is slim.  Patients who have had fractures or are at very high risk of fracture may not be receiving the treatment they ultimately need.  Coverages of medications can change based on the insurance the patient has.  The cost to the patient can change from commercial plans to Medicare or Medicaid plans.  Tools such as copay cards are helpful until CMS plans are involved.  The rise of Medicare Advantage plans also creates a challenge with cost for patients who elect for these plans. 

So now what?

For those of us who specialize in this area, I doubt that anything I said surprised you.  If anything, it is validating what you have been thinking for years.  Many thoughts come to mind after reading this article, including how we can tackle this issue of adherence.  Can we simplify these treatment regimens for patients?  What innovative approaches can we have in the medical and pharmaceutical communities regarding treatment regimens and costs for our high-risk patients?  How can we redesign patient education to be more interactive and engaging for patients so they take ownership of this disease and improve adherence?  Can we optimize treatment delivery systems for these patients to improve access to specialized care?

Adherence is a multifaceted problem, and the solution will be heterogeneous. However, we can improve the overall adherence of these patients by streamlining regimens, enhancing education, optimizing specialized treatment systems, and creating innovative solutions for financial barriers.