Osteoporosis, the literal translation meaning ‘porous bones’, occurs when bones lose density, become fragile and can easily fracture.1 This can have a subsequent devastating impact on mobility, independence, quality of life and mortality.2
Patients are usually unaware that they are suffering from osteoporosis until they experience a fracture which can occur following a fairly minor fall or injury.1
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Osteoporosis is a major burden for the NHS, including primary care services.
The National Osteoporosis Society has published an estimate of the total hospital and social care costs of managing hip fractures; the current figure quoted is approximately £2 billion,2 with 30% of all hip fracture hospital admissions stemming from residential or nursing care.3
Burden of GP consultations4
Mean change in number of GP visits after osteoporosis fracture vs. control.
In those patients over 60, the number of finished consultant episodes (FCEs) due to major fractures (wrist, vertebral and hip), when combined, is greater than the number of FCEs of other common diseases such as myocardial infarction, breast cancer, and dementia.5 This highlights the current burden of osteoporosis in the UK compared to other common diseases which are often higher profile in the public domain and the media.
Whilst osteoporotic fractures can be a major burden for the NHS in relation to cost and people resources, the outlook for those suffering can also be distressing. Hip fractures are the most severe fragility fracture, with potentially serious complications.6 Hip fractures result in a very high morbidity, with mortality rates over 20% in the first year.7
Given the ageing population, we can therefore anticipate an increase in fracture incidence, including hip fractures. Each year in the UK, there are over 70,000 osteoporosis-related hip fractures and this figure is set to rise as the population grows.8,9
Projections estimate that 24% of the UK population will be aged 65 and over in 2036.9
So what can be done to improve the outcome for both the NHS and patients?
Calcium and vitamin D are important and required nutrients for bone health and maintenance. The intake of calcium and vitamin D in a patient with bone loss is critical for optimal care.10
Not only are calcium and vitamin D important for bone health, they also optimise the effects of other treatments for osteoporosis.8
Unfortunately, some patients may be missing out. The table below illustrates that a significant number of patients are not being identified and treated for the secondary prevention of fragility fractures.
Patients treated with calcium or vitamin D post-fracture11
|-||% Patients treated 12 weeks post-fracture|
|Hip fracture||Non-hip fracture|
|Calcium (≥1g per day)||68%||34%|
|Vitamin D (800IU per day)||67%||32%|
The Committee appreciated that the general population, particularly the elderly population, cannot be assumed to have an adequate dietary intake of calcium and vitamin D. It was also considered important to note that adequate levels (normal serum concentrations) of calcium and vitamin D are needed to ensure optimum effects of the treatments for osteoporosis.
The Committee concluded that calcium and/or vitamin D supplementation should be provided unless clinicians are confident that women who receive treatment for osteoporosis have an adequate calcium intake and are vitamin D replete.
In addition, recent Guidance for CCGs on ‘Conditions for which over the counter items should not routinely be prescribed in primary care’ specifically excluded calcium and vitamin D for osteoporosis, and was only one of three exclusion groups within the vitamins and minerals category.14
Adherence is an important element in the challenge to prevent fragility fractures.
Chronic conditions often have low adherence, and this includes osteoporosis. Poor adherence has been called the ‘weakest link’ or the ‘Achilles’ Heel’ in the treatment of osteoporosis and research has shown that 44% of postmenopausal women with osteoporosis stopped taking their prescription-based medication for osteoporosis.14 When questioned why, 45% said this was due to medication side effects and 28% stated that they did not feel any improvements in pain.14
The benefit of a high compliance rate of calcium and vitamin D supplementation can be seen in one study which analysed 29 randomised trials. It found in 17 trials (n=52,625) where fractures were reported as an outcome, calcium and vitamin D treatment was associated with a 12% risk reduction in fractures of all types (risk ratio 0.88, 95% CI 0.83–0.95; p=0.0004). However, in trials where the compliance rate was high, the fracture risk reduction was significantly greater at 24% (p<0.0001).15
The same study also found improved therapeutic effects with calcium doses of 1200 mg or more than with doses less than 1200 mg (0.80 vs 0.94; p=0.006), and with vitamin D doses of 800 IU or more than with doses less than 800 IU (0.84 vs 0.87; p=0.03).15
Correct and long-term treatment for those suffering from osteoporosis could have a profound improvement on:
The following are important considerations when exploring ways to improve adherence:
Patient education programmes
Patient education programmes can also have a positive impact on patient behaviours with direct contact with the healthcare provider appearing to provide the most benefit in terms of improving health behaviours, including adherence and persistence with medication.14
In addition, other patient education programmes have also shown demonstrable benefits. A 2014 study which assessed daily text messaging service for patients who were prescribed blood pressure or lipid lowering drugs found that text messaging improved medication adherence versus no text messaging.21
Healthcare professionals can also affect compliance, both positively (by discussing osteoporosis, and the importance of treating this serious disease) or negatively (by not preparing patients for possible adverse effects).14
However, research indicates that nearly half of postmenopausal women with osteoporosis do not receive any information or advice on the importance of continuing treatment for osteoporosis or the treatment options available from their healthcare professional.14
Patient education and support
Many studies have shown that patients do not always understand prescription instructions and often forget considerable portions of what healthcare practitioners tell them.22
Research has demonstrated that patients’ understanding of their conditions and treatments is positively related to adherence, and that adherence, satisfaction, recall, and understanding are all related to the amount and type of information given.22
The Adcal-D₃® range provides:
- The UK’s largest choice of calcium and vitamin D preparations23,24
- Adcal-D₃® Caplets: Film coated swallowable tablets
- Adcal-D₃®: Tutti Frutti flavoured chewable tablets
- Adcal-D₃® Lemon: Lemon flavoured chewable tablets
- Adcal-D₃® Dissolve: Lemon flavoured effervescent tablets
- Calendar packaging for the entire range, with the aim of improving adherence by allowing patients to keep track of when they have taken their Adcal-D₃®
- AdcalConnect, a free of charge call or text reminder service, which has been developed specifically for patients prescribed Adcal-D₃® to help them remember to take their medication as prescribed
- Patients will receive 44 messages, decreasing in frequency over a 6 month period, to help build the habit of taking Adcal-D₃®
- Patients can be contacted either by text or short voice messages, whichever they prefer, and can choose to opt out of the service at any time
- Messages are only sent between the hours of 10am and 6.30pm
- A recommended daily dose of 1,200mg calcium and 800 IU vitamin D₃ which is clinically proven to reduce fractures25,26
- Adcal-D₃® Caplets - film coated27 for ease of swallowing
- Stability tested for usage with dosette box31
October 2018. UK/M001/0738
- Osteoporosis, NHS Choices. www.nhs.uk/Conditions/Osteoporosis/Pages/Introduction.aspx Last accessed Sept 2018.
- Protecting fragile bones. A strategy to reduce the impact of osteoporosis and fragility fractures in England. National Osteoporosis Society.
- Hip fracture management. NICE Clinical Guideline CG124, 2011.
- Dolan P and Torgerson DJ. Osteoporos Int 1998; 8:611-617.
- Kyowa Kirin Ltd. Data on file 001.
- Leung J, Kung C. Osteoporos Int 2010: 21(4); S605–S614.
- Schnell S, et al. Geriatric Orthopaedic Surgery & Rehabilitation 2010: 1(1); 6-14.
- NICE Technology appraisal guidance 160, October 2008.
- Overview of the UK population: July 2017. Office of National Statistics.
- Sunyecz J A. Therapeutics and Clinical Risk Management 2008: 4(4) 827-836.
- Royal College of Physicians 2011. Falling Standards, Broken Promises. Report of the national audit of falls and bone health in older people 2010.
- NICE Technology appraisal guidance 161, October 2008.
- Conditions for which over the counter items should not routinely be prescribed in primary care: Guidance for CCGs. NHS England. March 2018.
- Osteoporosis in the UK at…Breaking Point. September 2010.
- Tang B, et al. Lancet 2007; 370: 657-66.
- Leal J, et al. Osteoporos Int.2016; 27(2): 549-58.
- Kanis JA, Brazier JE, Stevenson M, Calvert NW, Lloyd Jones M. Treatment of established osteoporosis: a systematic review and cost-utility analysis. Health Technol Assess 2002; 6(29).
- Kling, JM, et al. Journal of Women’s Health 2014: 23(7); 563-572.
- Salkeld G, Cameron ID, Cumming RG, et al. Quality of life related to fear of falling and hip fracture in older women: a time trade off study. BMJ 2000; 320: 341-346.
- Christodoulou C, Cooper C. What is osteoporosis? Postgrad Med J 2003; 79: 133-138.
- Wald DS et al. PLOS One 2014; 1-9.
- Ashish A, et al. MedGenMed. 2005; 7(1): 4.
- eMIMS, June 2018.
- eMC, Calcium and Calcium & Vitamin D supplements SPCs. www.medicines.org.uk/emc. Last accessed June 2018.
- Chapuy MC, et al. N Engl J Med 1992; 327:1637-42.
- Tang BM, et al. Lancet 2007; 370:657-66.
- Adcal-D3 Caplet SmPC.
- Data on file.
- Halal Authority Board. Adcal-D3 Caplet Halal Certificate.
- Kosher Certificate.
- Report PS/RPT/12/007 Stability Report Dosing Boxes.
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