Osteoporosis medications have been proven effective in reducing fracture risk, yet there is still a significant lack of osteoporosis medication adherence and persistence. Doctors tend to misjudge their patients’ adherence to these helpful medications, believing that over 69% of their patients are adherent, while claims data shows that less than 49% of patients actually are. What’s more, it’s estimated that as many as 70% of patients that start treatment discontinue their osteoporosis medications within the first year. Regrettably, the suboptimal rates of adherence and persistence are largely responsible for a higher incidence of subsequent fracture and mortality. Finding more effective interventions to improve these suboptimal rates will help advance the quality of life, decrease mortality, and reduce the economic burden related to osteoporotic fractures.

The barriers to osteoporosis medication adherence are complex and challenging to overcome. They include a lack of health literacy and patient education, fear or intolerance of side effects, and polypharmacy. Unaddressed patient values, preferences, and capabilities also hinder adherence and persistence. And, unlike patients with conditions such as diabetes or congestive heart failure, patients with osteoporosis may be asymptomatic until they experience a fracture, leading them to experience a false sense of security and less likely to feel that medication treatment is necessary.

Because each patient’s barriers are unique and personal, interventions that prove effective for some patients may not be as effective for others. Therefore, personalized solutions that involve a partnership between the provider and the patient for shared decision-making are critical components of a successful program to improve adherence and persistence to osteoporosis medications. Specifically, multi-component approaches, those that combine several interventions tailored to the individual, appear to be more effective than single-component interventions.

The types of interventions that have been studied and for which there is evidence regarding their effectiveness (or lack therefor) primarily fall into four categories:

1. Patient education, that is, the provision of information,
2. Adjustments to the drug regimen (change in dosing regimen or alternative medication),
3. Monitoring and supervision (phone call reminders), and
4. Collaboration among an interdisciplinary team

Comparably to what is observed with other chronic conditions, patient education interventions, when incorporated as part of an educational-behavioral strategy, are more effective than providing education without counseling or patient-provider shared decision-making. Similarly, drug regimen adjustment interventions were more effective when combined with counseling or with personalization to the patient’s lifestyle. Monitoring and supervision, where the patient receives multiple phone call reminders to take their medication, was effective in increasing rates of implementation and preventing discontinuation, but even more so when combined with patient counseling. Finally, an interdisciplinary collaboration intervention (as a single component), where patients got specialty fracture care followed up by care from their PCP, was no more effective than an intervention where patients received initial and follow-up care from the specialty provider. But when the usual care was supplemented with an intervention comprised of a referral for a consultation with an endocrinologist and an educational program, implementation rates improved significantly.

Improve Osteoporosis Medication Adherence and Persistence

The literature seems to point to the increased effectiveness of multi-component interventions. Specifically, those with active patient involvement were the most effective in increasing adherence and/or persistence. Adding patient involvement, counseling, and shared decision-making helped optimize the traditional interventions to achieve better results. Clinicians seeking to improve outcomes and improve adherence and persistence to osteoporosis medications should aim to tailor their interventions to combine traditional methods with more individualized solutions that emphasize patient participation, patient-provider collaboration, and shared decision-making.

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Ross S, Samuels E, Gairy K, et al. A meta-analysis of osteoporotic fracture risk with medication nonadherence. Value Heal. 2011;14:571–581. doi: 10.1016/j.jval.2010.11.010.

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;29:2623–2637. doi: 10.1007/s00198-018-4759-3.

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Cornelissen D, de Kunder S, Si L, Reginster JY, Evers S, Boonen A, Hiligsmann M; European Society for Clinical and Economic Aspect of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO). Interventions to improve adherence to anti-osteoporosis medications: an updated systematic review. Osteoporos Int. 2020 Sep;31(9):1645-1669. doi: 10.1007/s00198-020-05378-0. Epub 2020 May 1. PMID: 32358684; PMCID: PMC7423788.