Persistence is key to preserving bone health

The complex instructions for osteoporosis medicines might stand in the way of adherence to these powerful bone builders.

By Susan J. Landers — Posted April 4, 2005

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Washington -- There are effective medications and practices to prevent bone loss, but physicians face a tough battle convincing patients to stay with them over the long haul.

"Women continue to put themselves at risk for fractures that can lead to pain, physical disability, loss of independence and even premature death by stopping osteoporosis treatment too soon," said Sydney L. Bonnick, MD, medical director of the Clinical Research Center of North Texas in Denton, Texas.

A national telephone survey revealed that as many as two-thirds of women participants who have postmenopausal osteoporosis discontinued their medication within one year. The survey was conducted between Dec. 14, 2004, and Jan. 5, 2005, by the Alliance for Aging Research and Opinion Research Corp. Support was provided by GlaxoSmithKline and Roche, which market a bone-strengthening medication.

Each year, about 1.5 million people have an osteoporosis-related fracture, said a surgeon general's report last fall. Although patients with osteoporosis can include children with birth defects and middle-aged men on certain medications, 80% of those affected by the disease are women, particularly postmenopausal women.

And compliance with treatment is not the only concern facing physicians. They must first convince patients that they are indeed at risk for osteoporatic fractures, said Laura Tosi, MD, chair of the Dept. of Orthopedic Surgery at Children's National Medical Center in Washington, D.C.

For example, a study in the January Bone and Joint Surgery reported that 40% of patients hospitalized with hip fractures refused a request to participate in follow-up treatment for osteoporosis because they were certain they didn't have the disease.

Even when treatment is started, all too often it stops, Dr. Bonnick said. "Sometimes women will say they just didn't realize it was that important."

In addition to adequate calcium intake, vitamin D and exercise, bisphosphonates are often prescribed to reduce fracture risk. But the medications come with very specific dosing instructions that may pose an inconvenience, Dr. Bonnick noted.

"They must be taken on an empty stomach, first thing in the morning, with water only, and then you have to wait for a specific amount of time before you can have your morning coffee or orange juice," she noted. Complaints of indigestion or heartburn also could cause some people to stop taking a bisphosphonate. Research has not found a greater risk of such side effects among those taking the drug, she said, but the medications are known to irritate the lining of the esophagus.

If patients don't think it is very important to take the medication and physicians don't persuade them otherwise, the most common response is to stop taking it. "But if you realize how important taking the medication really is, you might consider that the upset stomach or indigestion could have happened anyway, and you could go ahead and treat it rather than stop the medication," Dr. Bonnick said.

Research is also continuing on ways to make the drugs easier and more convenient to take. A bisphosphonate that needs to be taken only once a month rather than daily or once a week, as is the case currently, soon could reach the market.

The majority of the 352 primary care physicians and obstetricians and gynecologists surveyed by the alliance reported that when once-a-week doses of bisphosphonates became available, treatment compliance rates improved, but not enough.

People who have witnessed the devastation from a hip fracture or the fracture of several vertebrae are more likely to comply with treatment dictates. "In cases where a grandmother had a horrible demise that resulted from a hip fracture, then I'm preaching to the converted," Dr. Tosi said.

The survey, to which 752 women between ages 50 and 80 responded, also revealed that doctors might not fully understand their patients' motivation to fight osteoporosis. The majority of the women reported that their desire to remain healthy and independent is what motivates them. But the majority of physicians believe patients' fear of fractures is the motivator.

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Facts on drug therapy for osteoporosis

There are two primary types of drug therapy for osteoporosis: antiresorptive agents and anabolic agents.

  • Antiresorptive therapies include bisphosphonates, estrogen, selective estrogen receptor modulators (SERMs) and calcitonin.
  • Antiresorptive agents lessen the risk of bone fracture by decreasing bone turnover, reducing bone loss and stabilizing bone microarchitecture.
  • The clear fracture benefits of postmenopausal hormone therapy demonstrated in the Women's Health Initiative trial are offset by adverse effects that include increased risk of stroke, cognitive impairment, deep vein thrombosis and breast cancer.
  • Anabolic agents expand the treatment approaches for osteoporosis in patients who continue to experience fractures or bone loss on an adequate program of general prevention and antiresorptive therapy.
  • Clinical trials have shown that intermittent parathyroid hormone (PTH) can increase bone mineral density and decrease vertebral and nonvertebral fractures in patients with severe osteoporosis.

Source: The AMA's Osteoporosis Management: The Online Series

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External links

AMA's Osteoporosis Management: The Online Series (link)

Alliance for Aging Research (link)

American Academy of Orthopaedic Surgeons (link)

U.S. surgeon general's report on bone health and osteoporosis (link)

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