Nonadherence to Osteoporosis Medication Initiation

Nonadherence to Osteoporosis Medication Initiation
Kristen Ross, Pharm.D., Fairview Pharmacy Services

Background: Osteoporosis is characterized by low bone mineral density leading to increased fracture risk. Approximately one out of every two people in the United States older than 50 years old is at risk for an osteoporotic fracture.  The National Osteoporosis Foundation recommends pharmacotherapy, primarily bisphosphonates, to slow disease progression in at-risk patients. Despite evidence that osteoporosis medications significantly reduce fracture risk and subsequent morbidity and mortality, medication adherence has been suboptimal. Previous research has estimated that one-third to half of all patients do not take their osteoporosis medications as directed in a persistent and compliant manner. Identifying the characteristics of patients likely to be nonadherent and their reasons for being nonadherent may help healthcare providers appropriately educate patients in order to maximize adherence. Although previous research has investigated adherence to osteoporosis medications in terms of persistence and compliance, little is known about adherence in terms of initiation.

Objective: The purpose of this study was to identify reasons patients stated for not starting osteoporosis treatment prescribed by their healthcare provider and patient characteristics that might predict nonadherence.

Study Design: Data originated from the Patient Activation after DXA Result Notification (PAADRN) study which was a double-blinded, randomized controlled trial investigating the effects of a patient-activation intervention on osteoporosis measures. The population consisted of patients aged 50 years or older presenting for DXA at three academic health centers in the United States between February 2012 and August 2014. The investigators focused on a subset of patients whose providers prescribed pharmacotherapy for osteoporosis or osteopenia based on their DXA results. Patients completed three interviews at baseline, 12 weeks, and 52 weeks after DXA. Several characteristics were measured including: demographics, health habits, osteoporosis knowledge using the “Osteoporosis and You” scale, DXA results, and FRAX risk. In addition, adherence to initiation of the medication was assessed by asking patients if their provider prescribed a new or different medication and whether the patient had started it. Those who stated that they did not start the medication were asked why as an open-ended question and interviewers categorized these patient reports. Adherers were compared with nonadherers and temporary nonadherers using Pearson chi-squared tests for categorical variables, F tests for continuous variables, and multivariable multinominal logistic regression. Nonadherers were defined as patients who decided not to take the prescribed medication at all. Temporary nonadherers included patients waiting until another procedure was performed, waiting to schedule an infusion appointment, or waiting to see whether the treatment would be covered by their insurance.

Results: Of the 7749 patients in the PAADRN study, 790 reported 12 weeks after DXA that their health care provider had prescribed a new or different osteoporosis medication. The demographics for this group were a mean age of 66.8 years, 87.2% female, and 84.2% Caucasian. Concerning adherence rates, 24.8% of patients reported that they did not start their prescribed medication. Of that percentage, 5.8% indicated only temporary nonadherence and 19% indicated that they decided not to take the prescribed medication at all. The only patient characteristic significantly associated with nonadherence was osteoporosis knowledge, with those having better knowledge being less likely to take their medications (p<0.05). The most common patient-reported reasons for nonadherence were fear of adverse effects (53.3%), a dislike of taking medicine (25.3%), and the belief that the medication would not help their condition (16.7%).

Conclusions: One in four patients who were prescribed osteoporosis pharmacotherapy declined treatment because they feared potential adverse effects, did not like taking medicine, or believed that the medication would not help their condition. These findings suggest that improved patient counseling on the potential adverse effects of osteoporosis treatment and the risk-benefit ratio may increase adherence rates.


  1. Hall SF, Edmonds SW, Lou Y, et. al. Patient reported reasons for nonadherence to recommended osteoporosis pharmacotherapy. J Am Pharm Assoc. 2017;57(4):503-509.

  2. Qaseem A, Forciea MA, McLean RM, et. al. Treatment of low bone density on osteoporosis to prevent fractures in men and women: a clinical practice guideline update from the American College of Physicians. Ann Intern Med. 2017;166(11):818-839.  

  3. Cosman F, de Beur SJ, LeBoff MS, et. al. Clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int. 2014;25(10)2359-81.

  4. Kathawala P, Badamgarav E, Ryu S, et. al. Systematic review and meta-analysis of real-world adherence to drug therapy for osteoporosis. Mayo Clin Proc. 2007;82(12):1493-501.

  5. Cram P, Wolinsky FD, Lou Y, et. al. Patient-activation and guideline-concordant pharmacological treatment after bone density testing: the PAADRN randomized controlled trial. Osteoporos Int. 2016;27(12):3513-3524.