This article is brought to you by FLAVORx

The Problem

Patient adherence, defined by the World Health Organization as the extent to which a person's behavior—taking medication, following a diet, and/or executing lifestyle changes—corresponds with agreed recommendations from a health care provider, will often predict successful treatment of medical conditions, specifically with regard to medications.¹ Poor adherence to drug therapies, however, continues to be problematic in the United States.

Statistics show that every year roughly 125,000 deaths and 10% of hospital admissions are attributed to a lack of adherence to medications.² In fact, almost 29% of Americans will stop taking their medications before they run out, potentially leading to a worsening of current health conditions and/or increased health care costs.³ Poor adherence is especially problematic for pediatric patients, with an estimated 50% of children taking medications inadequately.⁴ Noncompliance with drug therapies alone results in an estimated $100 billion in additional health care costs each year in the United States.²

Studies have also shown that approximately 22% of Americans will take less medication than was prescribed.³ Early cessation of therapy may be attributed to adverse drug reactions, resolution of patient symptoms, costs, or difficulty administering drugs either due to route of administration (eg, suppository), frequency of drug administration, complicated dosing instructions, and/or poor palatability (particularly in children).

Incomplete therapy with antibiotics can be especially problematic, leading to potential resistance against microorganisms, increased risk of spreading illness to others, persistent symptoms, need for additional doctor visits/consultations, use of extra drugs, unnecessary hospital admissions, increased health care costs, and deterioration of health.^5,6 Former US Surgeon General C. Everett Koop once said, "Drugs don't work if the people don't take them."² Thus, what can be done to increase patient medication adherence in order to enhance the successful treatment of medical conditions?

The Resolution

Recognizing the necessity and importance of improving outcomes, pharmacists have developed numerous methods and devices to assist patients with taking their medications. Over the past several decades, methods such as daily, weekly, and monthly pill boxes, alarm clocks, postcard/ telephone refill reminders, and frequent counseling have been employed by many pharmacists in numerous settings to increase patient adherence. Pharmacists also have been instrumental in making recommendations of combination therapies to reduce the pill burden for patients or therapeutic interchanges to simplify the medication regimen and/or minimize adverse drug effects. Though these methods are ways of reminding the patient to take his or her medication or easing the administration of medications, they do not eliminate the problem of poor palatability with many commonly encountered drugs.

The Taste Test

Although taste is a subjective sensation, knowledge about the differences in taste among children and adults can provide insight into why patients may be reluctant to take certain medications. The average adult has approximately 10,000 taste buds that can be found on all surfaces of the tongue, inside the cheek, and down the esophagus. These taste buds in adults are typically regenerated every 10 days, and the total number of taste buds begins to decline by age 50.⁷ On the other hand, children have taste buds that regenerate at a much faster rate. They also tend to have a much more heightened sense of taste, particularly with bitter substances.⁷ Recent evidence has shown that genetics may also play a role in the perception of bitter tastes.⁸

To avoid bad tastes associated with some medications on the market, patients and/or parents of pediatric patients will attempt to remedy the situation themselves through refrigeration (coldness numbs the taste buds) of certain medications (eg, amoxicillin/ potassium clavulanate suspensions) or mixing medications with chocolate syrup, milk, fruit juices, such as orange and grapefruit juice, and/or carbonated beverages.⁹ Patients may not be aware, however, that certain medications are not compatible with common foods and drinks. Administration of grapefruit juice with statins, calcium channel blockers, certain antiarrhythmics (eg, amiodarone and quinidine), protease inhibitors, and immunosuppressants (eg, cyclosporine and tacrolimus) has been associated with increased concentrations of these drugs, potentially leading to toxic levels in the body.¹⁰ Taking acid-labile medications (eg, penicillin or amoxicillin/potassium clavulanate) with acid-containing products, such as orange juice or other fruit juices, may reduce the effectiveness of these drugs.Milk and even small amounts of chocolate syrup containing calcium can reduce the absorption of certain antibiotics such as tetracycline and quinolones (eg, ciprofloxacin, levofloxacin, moxifloxacin) and iron supplements.

In an attempt to improve the taste of certain medications with poor palatability, pharmacists may add safe flavoring agents to ease patient administration. Some pharmacists may not be aware, however, that pediatric response to a medication's taste differs vastly from that of the adult. Because medications are typically administered outside of a pharmacy setting, a pharmacist may not observe or experience the struggle faced by some parents and may overlook the opportunity to assist with patient adherence.

Until recently, pharmacists may have viewed the flavoring process as laborious and time-consuming, due to uncertainty with regard to the choice and amount of flavoring agent to add. Companies such as FLAVORx, however, have improved the efficiency of flavoring by simplifying the methods to a quick 1-to 2-minute process for pharmacists despite time constraints.¹¹

FLAVORx (www.flavorx.com) offers a list of commonly prescribed medications with poor palatability that can assist pharmacists who may be unaware of how most medications taste. The unique "Wheel of Yuck" provides pharmacists with flavoring recommendations for those drugs with poor palatability. FLAVORx currently offers 42 flavors that have all been medically tested for safe and effective use in medications. All flavors are dye-free and sugar-free; do not contain casein, gluten, or aspartame; are nonallergenic; contain less than 8% alcohol; and are approved by the FDA. Because FLAVORx flavors are highly concentrated, only a few drops are necessary to flavor most prescriptions, regardless of medication volume. While FLAVORx is used with liquid medications, flavors may also be added to suspensions that have been formulated from capsules and/or tablets by the pharmacist. To date, the FLAVORx system has flavored over 40 million prescriptions without any incidence of allergy, adverse drug reaction, or reduced efficacy in the medication. Independent studies assessing FLAVORx flavors have found an increase in compliance among pediatric patients from an average of approximately 50% to over 90%.¹²

In addition to offering a variety of flavors, the FLAVORx formulary utilizes proprietary products, such as Bitterness Suppressor, Sweetening Enhancer, and Vitamin/Iron Masking Agent, to improve palatability of medications that trigger a bitter or foul sensation or trigger smell receptors. It is recommended that patients taste the products that have been flavored prior to leaving the pharmacy so that changes can be made if necessary. In addition, FLAVORx offers a 24-hour technical support system to service its 35,000 participating pharmacies nationwide and answer any pharmacist or patient questions on flavoring.⁹

Along with conventional tools and methods pharmacists have employed to improve patient adherence, flavoring is now another option that is safe, easy, efficient, and proven to increase adherence.

Dr. Dana Brown is an assistant professor of pharmacy practice at the Lloyd L. Gregory School of Pharmacy, Palm Beach Atlantic University. Mr. Gregory Brown is a pharmacy manager at Sav-On Pharmacy/Albertsons.

For a list of references, send a stamped, self-addressed envelope to: References Department, Attn. A. Rybovic, Pharmacy Times, Ascend Media Healthcare, 103 College Road East, Princeton, NJ 08540; or send an e-mail request to: arybovic@ascendmedia.com.