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Recent data suggest that approximately 45 million persons in the United States have osteopenia or osteoporosis and are consequently at high risk for fracture. The number of patients with low bone mass is likely to grow with the aging of the US population; by 2020, 1 in 2 Americans aged ≥50 years will either have, or be at high risk for developing, osteoporosis.¹ Fractures—the most important consequence of osteoporosis—are common and costly, and can substantially compromise quality of life. Approximately 1.5 million individuals have fractures secondary to bone disease each year, and approximately 40% of white women aged ≥50 years will experience a fracture during the remainder of their lives. Along with causing approximately 500,000 hospitalizations and 2.6 million physician visits, osteoporosis generates direct care expenditures that currently approach $18 billion annually.¹ The personal and societal costs of osteoporosis will only grow in parallel with the increasing prevalence of the disease. The impact of osteoporosis—and the importance of timely prevention, assessment, diagnosis, and treatment—was recently recognized by the US Surgeon General’s office in its first report on bone health and osteoporosis.¹

Clinical and epidemiologic evidence clearly indicates that the progression from healthy bone to osteopenia to osteoporosis can be delayed or prevented altogether. First and foremost, lifestyle changes—particularly when instituted early—may delay or prevent osteoporosis in many patients. In particular, physical activity and adequate calcium and vitamin D intake are major contributors to bone health. Second, a broad range of safe and highly effective pharmacologic measures are available that reduce the risk of fracture in individuals with osteopenia and osteoporosis. Third, our increasing knowledge about risk factors for osteoporosis and fracture, as well as the ready availability of accurate, noninvasive tools for measuring bone density and bone mass, can be leveraged to identify patients most at risk for fracture.

Although substantial progress has been made in identifying patients at risk for fracture and instituting appropriate lifestyle changes and pharmacologic therapy, much remains to be done to improve bone health. At the front line of patient care, primary care providers and obstetricians/gynecologists have an important role to play in ensuring that patients at risk for osteoporosis are identified early so that lifestyle changes may be instituted to delay its progression.

For patients at risk for fracture and in need of pharmacologic treatment, adequate care does not end with writing the prescription. Research shows that across therapeutic areas—and regardless of disease severity—few patients remain on treatment over the long term. Those with osteoporosis are no exception. In fact, because osteoporosis is a “silent” disease, in the absence of overt fracture, a higher percentage of patients may discontinue medication prematurely compared with those who have symptomatic diseases. Consequently, strategies to improve compliance and persistence with lifestyle changes and treatment must be considered right at the start. Primary care providers can improve compliance and persistence among patients with osteopenia or osteoporosis who are eligible for pharmacologic treatment by selecting agents that suit the patient’s lifestyle and preferences. Once therapy has begun, patient education and regular follow-up are critical to ensure that patients understand the continued need for therapy, are satisfied with their treatment, and take their medications according to directions.

This supplement to The American Journal of Medicine, which is based on a roundtable meeting of experts in the fields of bone health and patient compliance, addresses the large and growing need for practical information on the prevention and treatment of osteoporosis.

The first article, which I coauthored with Dr. Margery Gass, provides a summary of the epidemiology and consequences of osteoporosis, risk factors and diagnosis, and guidelines for the management of the disease. The article also presents a general overview of both nonpharmacologic and pharmacologic modalities for prevention and treatment.

The second article, by Dr. Joyce A. Cramer and Dr. Stuart Silverman, examines the problem of noncompliance across therapeutic areas and discusses general strategies to improve compliance and persistence with medication.

Bisphosphonates are among the most commonly prescribed medications for the prevention and treatment of osteoporosis. However, these agents have special requirements—primarily related to dosing complexity—that can negatively affect long-term persistence with their use. In their article, Dr. Ronald D. Emkey and Dr. Mark Ettinger examine these problems, and evaluate the efficacy of extended-interval dosing (e.g., weekly or monthly) and the potential impact of less frequent administration on compliance and persistence.

Monitoring the efficacy associated with antiresorptive therapy is an important part of successful management of osteoporosis. Dr. Sydney Lou Bonnick and Dr. Lee Shulman then explore the relation between bone mineral density, bone turnover markers, and fracture risk, and summarize recommendations for the timing and frequency of monitoring and the selection of appropriate densitometry techniques and skeletal sites. In addition, they address the utility and availability of bone turnover markers for monitoring patients in clinical practice.

In the final article, Dr. Deborah T. Gold and Nurse Betsy McClung draw on research from a broad range of therapeutic areas to explore the role of patient education and support groups in improving compliance and persistence with osteoporosis therapy, and suggest practical measures to help patients remain on treatment. The data they review indicate that involving the patient in therapy through education, monitoring, and frequent feedback are integral to ensuring optimal treatment.

A word about definitions: within this supplement, compliance is defined as the extent to which a person’s behavior—in terms of taking prescribed medication, following dietary regimens, or instituting recommended lifestyle changes—is consistent with medical or health advice. Compliance is synonymous with adherence, but is used within this supplement because it is the medical subject heading term used by the National Library of Medicine. Persistence is defined as the duration of treatment; thus, nonpersistence is defined as treatment discontinuation without medical recommendation.

In summary, osteoporosis is not an inevitable consequence of aging. Primary care providers, because of their close relationship with patients, are ideally positioned to identify those in need of treatment and to encourage patients to remain on therapy. Healthcare providers may have a profound positive effect on the bone health of their patients by implementing the recommendations in this supplement and by following current diagnosis, monitoring, and treatment guidelines.

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Reference 

1. US Department of Health and Human Services . Bone Health and Osteoporosis (a Report of the Surgeon General) . Rockville, MD: US Dept of Health and Human Services, Public Health Service, Office of the Surgeon General; 2004;
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