The lifetime risk for fragility fractures due to osteoporosis after the age of 50 years is about 50% in women and 20% in men. The resultant high morbidity, mortality, and economic costs for elderly people have stimulated the development of effective interventions to reduce fracture risk. Despite these advances, however, the question remains as to whether patients take their treatment as prescribed (compliance) and for the recommended duration (persistence) [1].

Compliance and persistence are poor in at least 50% of patients during the first year of treatment for osteoporosis, and in 80% after 3 years. Most instances of inadequate compliance and persistence occur within 3 months of the start of treatment, and are associated with higher rates of fracture than those observed when compliance and persistence are good. Higher rates of prescription refills were also associated with lower fracture rates. The stage at which inadequate compliance and persistence compromise effectiveness is unknown. However, fracture rates increase when compliance falls below 50%. The causes of poor compliance and persistence are poorly understood. Putative causal factors such as age, previous history of fracture, use of multiple medications, and comorbidities explain less than 10% of variability in compliance.

Several strategies have been proposed to improve compliance and persistence. Patient education, either as written materials or consultation, can enhance compliance and persistence, albeit modestly. Monitoring of treatment outcomes by measurements of bone remodeling or bone mineral density may also have a role. Early follow-up, with an opportunity to discuss treatment issues, might improve compliance efficiently.

Patient education could produce additional improvements. However, other as yet unidentified measures will be needed to ensure that all potential benefits of treatment are realized. Meanwhile, monitoring of compliance and persistence should be regarded as an integral part of the management of osteoporosis.

1. Compston JE et al. Lancet. 2006;368:973-974.