This study examined compliance and persistence with osteoporosis medications among 150 post-menopausal Israeli women. Overall, 57% were compliant with their medications, defined as having a medication possession ratio over 80%. Compliance was higher for percutaneous treatments like zoledronic acid and denosumab than for oral bisphosphonates. Of those on oral bisphosphonates, 77% persisted with treatment over 12 months without gaps of more than 30 days. For those on a scheduled drug holiday, 81% were not concerned about resuming treatment. Most patients, 57%, preferred annual treatment options over more frequent dosing schedules.

1. Compliance, Persistence and Preferences towards Osteoporosis
Treatment among Post-menopausal Israeli Women during
Active Therapy or Drug Holiday
Alona Eliasaf, B Pharm1*, Alina Amitai, Pharm D1, Mira Maram Edry, MD2, Shimona Yosselson Superstine,
Pharm D MPH3, Pnina Rotman Pikielny, MD4,5
1Division of Clinical Pharmacy, Pharmacy Services, 2Medical Management Department, 4Bone Health Service, Endocrine Unit,
5Department of Medicine E, Meir Medical Center, Kfar Saba, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University,
Tel Aviv, Israel, 3Division of Clinical Pharmacy, School of Pharmacy,
The Hebrew University of Jerusalem, Jerusalem, Israel *Pharm D candidate
Definitions4
Compliance - the extent to which a patient acts in accordance
with the prescribed interval and dose of a dosing regimen
Persistence - the duration of time from initiation to discontinua-
tion of therapy without exceeding prescribed intervals between
doses (permissible gaps)
Background
Osteoporosis treatments can reduce the risk of fractures by
30-50%, but patient compliance and persistence after one year
is only about 50%. Low adherence to treatment increases the risk
of fractures.1-3
Objectives
Determine compliance and persistence with osteoporosis therapy
among post-menopausal women treated at a metabolic bone
clinic and evaluate attitudes regarding resuming treatment
among patients on a drug holiday.
Methods
Compliance and persistence were assessed for the last 12 months
of treatment.
1. Compliance was assessed based on the medication possession
ratio (MPR), representing the number of doses dispensed in
relation to those prescribed.4
2. Persistence was defined as duration of treatment without
> 30-day gap in refills. This was assessed as a dichotomous
variable categorizing patients as “persistent” or
“non-persistent".4
3. Data were collected by a single clinical pharmacist, who
interviewed patients before a routine outpatient visit.
Additional information was abstracted from medical records.
Results
Of 150 patients interviewed (70.1±8.1 years-old), 86 (57%) were taking
medication
MPR calculated from medication possession documented in the
electronic database, was ≥80% in 80% of patients and <50% in 12% of
patients
Statistically significant difference in the mean MPR was found between
percutaneous and oral drug therapies (p=0.004).
Of 39 patients who took oral bisphosphonates, 77% persisted with
treatment.
Of 35 patients actively taking oral bisphosphonates, 89% took them
as directed, compared to 27% of 11 patients taking strontium ranelate
(p<0.0001)
Of 64 patients on a scheduled medication break, 81% did not express
concerns about resuming treatment.
Of 150 patients interviewed, 57% preferred annual treatment
compared with more frequent treatment options
Conclusions
Compliance and persistence were higher than reported in the literature. MPR for strontium ranelate was lower than for zoledronic acid and
denosumab.
Compliance with percutaneous treatments (zoledronate, denosumab and teriparatide) was higher than for oral medications as reported before5,6
A high rate of patients took oral bisphosphonates as directed, compared with lower rates for strontium ranelate
High persistence and compliance might be specific to patients from a dedicated Bone Disease Clinic
Most patients on a scheduled drug holiday were not concerned about resuming treatment and did not have a preferred medication option
These results indicate that a trusting relationship between doctor and patient might be an important factor in medication compliance
1. Seeman E, Compston J, Adachi J, et al. Non-compliance: the Achilles' heel of anti-fracture efficacy. Osteopors Int 2007;18:711-9.
2. Sambrook P. Compliance with treatment in osteoporosis patients--an ongoing problem. Aust Fam Physician 2006;35:135-7.
3. Siris ES, Harris ST, Rosen CJ, et al. Adherence to bisphosphonate therapy and fracture rates in osteoporotic women: relationship to vertebral and nonvertebral fractures from 2 US claims databases. Mayo Clin Proc; 2006: Elsevier p. 1013-22.
4. Cramer JA, Roy A, Burrell A, et al. Medication compliance and persistence: terminology and definitions. Value in Health 2008;11:44-7.
5. Ziller V, Zimmermann S, Kalder M, et al. Adherence and persistence in patients with severe osteoporosis treated with teriparatide. Curr Med Res Opin 2010;26:675-81.
6. Kendler DL, McClung MR, Freemantle N, et al. Adherence, preference, and satisfaction of postmenopausal women taking denosumab or alendronate. Osteopors Int 2011;22:1725-35.
Raloxifene
Oral
bisphosphonate
Strontium
ranelate
Zoledronicacid
Teriparatide
Denosum
ab
Oral bisphosphonate
Strontium ranelate
Zoledronic acid
Teriparatide
Denosumab
Raloxifene
N=86
Overall, 61% were taking oral medication, mostly a bisphosphonate,
while 39% were on percutaneous treatment.
What is your opinion regarding resuming previous drug after
a "drug holiday"
Opinion
N=64
Causes for refusal
Adverse effects
13%
Lack of
effectiveness
13%
Inconvinient
instructions
3%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Preference of annual treatment compared with more
frequent treatments
N=150
Other frequency
treatments
Annual treatment
Not Taking medication Taking medication
P=0.015
Distribution of drug therapies in the study population Mean Medication Possession Ratio (MPR) for drug therapies
** *
33%
67%
53%
48%
*p=0.001
* Bonferroni post-hoc comparison Strontium ranelate ≠ Zoledronic acid and Denosumab
120
100
80
60
40
20
0
MPR(%)
83.5
*
70.5 97.5
*
100.0 85.5
*
100.0