Osteoporosis affects an estimated 10 million adults in the United States and an additional 43 million have low bone mass.1 These numbers — along with the rate of fragility fractures — are expected to climb as the elderly population continues to increase, further underscoring the need for adequate and timely treatment for patients with osteoporosis. However, there are significant knowledge gaps regarding treatment in this population, as noted by a panel of experts convened by the National Institutes of Health Office of Disease Prevention, the National Institute of Arthritis and Musculoskeletal and Skin Diseases, and the National Institute on Aging.2 (See: Research Needed to Improve Osteoporotic Drug Therapy: Takeaways From NIH Pathways to Prevention Workshop.)
Barriers to pharmacotherapy for osteoporosis are among the areas identified as warranting further investigation to reduce the elevated mortality and morbidity rates associated with the disease.2 The panel reported a need for research on the efficacy of various therapies, as well as “studies that determine which patients initiate treatment, studies that identify ways to improve adherence to long-term osteoporotic drug therapies, and research that determines the best context for shared decision making.”
Some of these barriers were examined from the patient’s perspective in a study published in March 2019 in the Journal of Hand Surgery.3 Of the 325 patients with upper fragility fractures who completed surveys (63.1% women; mean age, 64.1 years), 85.7% said they had never been prescribed drugs for low bone density, 14.0% did not want to take more medications than they already were, 10.4% were concerned about potential side effects, 4.3% had conflicting information from providers, and 1.8% reported financial limitations.
These observations align with earlier findings that point to both physicians’ poor compliance with clinical guidelines and patients’ poor adherence to osteoporosis medication (less than 50%, according to study results3,4) as barriers to adequate treatment. The investigators in the 2019 study concluded that a “sizeable gap remains between current practice and optimal osteoporosis education and management.”3
In a systematic review published in 2018 in the Archives of Osteoporosis, researchers cited insufficient patient education as a factor contributing to low patient adherence.5 They examined 16 studies and identified “unmet information needs” reported by patients in the following areas: the nature of osteoporosis/fracture risk, the purpose of and need for medication, advice regarding self-management (vs focusing solely on pharmacologic interventions), understanding the role of bone densitometry, and regular follow-ups for medication monitoring and support.
On the part of physicians, failure to “elicit and address information needs appears to be associated with poor treatment adherence, deterioration of the doctor-patient relationship and important psychosocial consequences,” wrote the researchers. Healthcare providers who care for patients with osteoporosis “should reflect on to what extent they elicit or facilitate the expression of information needs and to what extent their core explanations relating to osteoporosis address” the topics described above.
A 2018 study published in Current Osteoporosis Reports explained the importance of perceived risk as a factor influencing medication adherence.4 Researchers noted that patients may not have an accurate perception of the risks involved in forgoing osteoporosis medications, and these misperceptions are partly based on their understanding of the information provided to them by clinicians.
To further explore barriers to osteoporosis treatment, Endocrinology Advisor checked in with one of the study investigators: Stuart L. Silverman, MD, FACP, FACR, Clinical Professor of Medicine at Cedars-Sinai Medical Center and University of California, Los Angeles School of Medicine, and Medical Director of the Osteoporosis Medical Center, a nonprofit research organization in Beverly Hills, California.
Endocrinology Advisor: What are some of the main patient barriers to osteoporosis drug therapy?
Stuart L. Silverman, MD, FACP, FACR: Osteoporosis is underdiagnosed and undertreated, and only about a quarter of patients with a fragility fracture are treated.
Patient barriers to therapy include:
· The perception that fractures are a natural result of the aging process, not a condition.
· Patient denial: for example, “I can’t have osteoporosis — no one in my family has it, and I exercise and take calcium.”
· Concerns regarding medication side effects, such as osteonecrosis of the jaw and atypical femoral fracture (ie, a medicine that helps bone should not break bones).
· Concerns regarding treatment efficacy.
Endocrinology Advisor: What are other key findings regarding patient nonadherence to osteoporosis treatment?
Dr Silverman: There are two types of nonadherence: the primary type is patients who do not fill their prescriptions, and the secondary type is patients who are not persistent with therapy. We have found that patients likely to have primary nonadherence are those who have not taken other prescription medications or who take multiple medications. In a similar fashion, risk factors for decreased persistence include polypharmacy, advanced age, and depression.6,7
Endocrinology Advisor: How should clinicians approach this issue in practice?
Dr Silverman: The most important factor is that the patient trusts their healthcare provider, who needs to communicate risk in a way that the patient understands. I suggest that physicians and other healthcare providers take the time to understand the patient’s perspective. For example, what are their biases against taking medications? What are important areas in the patient’s life on which osteoporotic fracture would have an impact? A numerical risk score for fracture, such as FRAX, may be less meaningful to patients than explaining the potential loss of independence and social roles that would result from an additional fracture.
1. NOF releases updated data detailing the prevalence of osteoporosis and low bone mass in the US [press release]. Washington, DC: National Osteoporosis Foundation; June 2, 2014. https://www.nof.org/news/54-million-americans-affected-by-osteoporosis-and-low-bone-mass/.
2. Siu A, Allore H, Brown D, Charles ST, Lohman M. National Institutes of Health Pathways to Prevention Workshop: research gaps for long-term drug therapies for osteoporotic fracture prevention. Ann Intern Med. 2019;17(1):51-57.
3. Mora AN, Blazar PE, Rogers JC, Earp BE. Patient perceptions and preferences for osteoporosis treatment [published online March 22, 2019]. J Hand Surg Am. doi:10.1016/j.jhsa.2019.01.018
4. Silverman S, Gold DT. Medication decision-making in osteoporosis: can we explain why patients do not take their osteoporosis medications? Curr Osteoporos Rep. 2018;16(6):772-774.
5. Raybould G, Babatunde O, Evans AL, Jordan JL, Paskins Z. Expressed information needs of patients with osteoporosis and/or fragility fractures: a systematic review. Arch Osteoporos. 2018;13(1):55.
6. Yeam CT, Chia S, Tan HCC, Kwan YH, Fong W, Seng JJB. A systematic review of factors affecting medication adherence among patients with osteoporosis. Osteoporos Int. 2018;29(12):2623-2637.
7. Grenard JL, Munjas BA, Adams JL, et al. Depression and medication adherence in the treatment of chronic diseases in the United States: a meta-analysis. J Gen Intern Med. 2011;26(10):1175-1182.