Review Adherence, persistence, concordance: do we provide optimal management to our patients with osteoporosis? Bernard Cortet a, * , Olivier Bénichou b a University Department of Rheumatology, Lille Teaching Hospital, 59037 Lille cédex, France b Women’ s Health Department, Lilly, Suresnes, France Received 26 July 2005; accepted 15 February 2006 Available online 26 July 2006 Abstract The last two decades have witnessed numerous advances in the treatment of chronic diseases, most notably those occurring in postmenopausal women. An insidious course and minimal symptoms often characterize chronic diseases, with the result that long-term adherence to prescribed treatment regimens may be difficult to obtain. Poor compliance has been abundantly documented, particularly in patients with hypercholester- olemia, hypertension, or diabetes mellitus. Many factors may contribute to poor compliance, including the unobtrusiveness of the symptoms, limited patient awareness of the potential severity of the disease and of the benefits expected from optimal treatment, low level of education, fear of adverse effects from medications, and cost of medications. The effects of these factors vary across countries, in particular according to the characteristics of healthcare systems. Several strategies are being developed to measure compliance and to identify reasons for non-compliance. Attention is turning to methods for improving compliance, some of which rest on general principles and others on the specific characteristics of each disease. Few data are available on compliance with treatments for osteoporosis, since these were introduced only within the last decade. In many studies, the reference standard was hormone replacement therapy (HRT), whose use is decreasing markedly as a result of recent data on adverse effects. Available studies of bisphosphonate therapy indicate a less than 50% continuation rate after 1 year. The few comparative studies published to date have methodological flaws that preclude definitive conclusions. Compliance has been equally poor with all available bispho- sphonates. Although statistically significant, the improvements produced by weekly dosing have been modest, about 10%, indicating a need for further compliance-enhancing strategies. Conflicting results were obtained from the few studies addressing the potential of bone turnover marker assays for influencing compliance. Having a nurse inform patients about the disease and the importance of compliance with dosing recommenda- tions holds promise for improving compliance. © 2006 Elsevier SAS. All rights reserved. Keywords: Osteoporosis; Adherence; Persistence; Compliance; HRT; Hormone replacement therapy; Raloxifene; Bisphosphonate 1. Introduction Osteoporosis is common, causing an about 40% lifetime fracture risk in women older than 50 years. Major disability results from osteoporosis, which also leads to excess mortality [1], most notably via hip fractures and vertebral fractures [2]. Nevertheless, osteoporosis is underdiagnosed, for multiple rea- sons. In less than 10 years, the treatment armamentarium for osteoporosis has expanded considerably. New medications have been proved effective in decreasing the risk of fractures, most notably at the spine, which is the chief target of osteo- porotic fractures. However, the proportion of patients who are taking these drugs remains low. Several observational studies showed that treatment durations were too brief to ensure opti- mal management. Similar findings were obtained regarding other chronic diseases that are common in postmenopausal women, such as hypercholesterolemia and hypertension. All these conditions produce little or no symptoms, a characteristic conducive to poor adherence with prescribed medication regi- mens. Poor adherence with treatments for osteoporosis has many adverse consequences. First, the therapeutic effect of the med- ications is diminished or absent. Second, the risk of adverse effects is increased if the medication is not taken as directed. http://france.elsevier.com/direct/BONSOI/ Joint Bone Spine 73 (2006) e1–e7 * Corresponding author. E-mail address: bcortet@chru-lille.fr (B. Cortet). 1297-319X/$ - see front matter © 2006 Elsevier SAS. All rights reserved. doi:10.1016/j.jbspin.2006.02.006