Patient Treatment Preferences for Osteoporosis

In the U.S. today, 10 million Americans have osteoporosis, and 50% of women and 25% of men will have an osteoporotic fracture their lifetime (1). The estimated national direct expenditure for osteoporotic fractures is over 47 million dollars per day. More importantly, osteoporotic fractures result in significant functional impairment, decreased quality of life, and increased mortality (2). The impact of this major public health problem is expected to increase exponentially as the population ages. Measures used to reduce bone loss, including calcium and vitamin D supplementation, regular weight-bearing exercise, and avoidance of tobacco and excessive alcohol, have essentially no risk and are generally recommended for all patients. Currently available prescription medications to treat osteoporosis include bisphosphonates, calcitonin, hormonal replacement therapy, raloxifene, and teriparatide (human recombinant parathyroid hormone, rhPTH). Results from the Women’s Health Initiative, however, raise concerns regarding the long-term use of hormonal replacement therapy as a first line agent for treatment of osteoporosis (2). Similarly, the role of raloxifene will be better elucidated when results from the STAR (The Study of Tamoxifen and Raloxifene) and RUTH (Raloxifene Use for the Heart) trials are available. Alendronate and risedronate are two oral bisphosphonates approved by the Food and Drug Administration for the treatment of osteoporosis which are now available as a single tablet taken once weekly. Both have been shown to decrease the risk of vertebral and hip fractures in large randomized controlled trials (3–5). Ibandronate, a monthly oral bisphosphonate has also been recently been approved for the treatment of osteoporosis. Intravenous bisphosphonates administered every three months decrease bone loss, but data demonstrating their ability to decrease fracture rates is lacking (6, 7). Zoledronic acid, a more potent intravenous bisphosphonate approved for the treatment of malignant hypercalcemia, was recently shown to have the same effect on bone turnover and bone density as oral bisphosphonates when administered once yearly (8). rhPTH, unlike the anti-resorptive agents, exerts its protective effect, in part, by stimulating bone growth. Despite producing increased bone turnover rates, rhPTH increases bone mineral density and decreases the risk of osteoporotic fractures by approximately 60% (9). Potential drawbacks associated with PTH include its route of administration (daily subcutaneous injections), high cost, and unknown long-term safety-profile. Because of the numbers of persons affected, the public health impact of treating osteoporosis is enormous. However, at the individual patient level many patients will not derive any benefit from treatment. For example, assuming the 10 year probability of sustaining a hip fracture for 75 year old women with osteoporosis is 22% (10); if 100 such women all took alendronate, 11 fractures would be prevented and 11 fractures would occur despite treatment. Thus, of 100 women taking treatment, 89 derive no benefit (11). Each individual patient’s preference for treatment will therefore depend on how he or she weighs the risk of future morbidity and possible mortality over the uncertain risk of long-term toxicity, bothersome adverse effects, and costs related to treatment. Consequently, treatment decisions should be based on physician expertise and explicitly derived patient preferences. This process of decision-making not only adheres to the principles of informed consent and patient autonomy, but also has been shown to increase patient satisfaction and improve compliance (12–14), both of which are essential to ensure successful long-term treatment of osteoporosis and ultimately prevent fractures. To the best of our knowledge, studies have not quantified patient preferences for prevention of osteoporotic fractures. Understanding patient preferences for prevention of osteoporotic fractures is especially important given that adherence to these medications is poor (15). The objective of this study was to examine patient treatment preferences for available and promising treatment options in osteoporosis using an interactive computerized questionnaire which elicits preferences based on how patients make trade-offs between the risks and benefits of the treatment options under consideration.