Increasing Patient Medication Adherence

This article is brought to you by FLAVORx

The Problem

Patient adherence, defined by theWorld Health Organization as theextent to which a person's behavior—taking medication, following a diet,and/or executing lifestyle changes—corresponds with agreed recommendationsfrom a health care provider,will often predict successful treatmentof medical conditions, specificallywith regard to medications.¹Poor adherence to drug therapies,however, continues to be problematicin the United States.

Statistics show that every yearroughly 125,000 deaths and 10% ofhospital admissions are attributed toa lack of adherence to medications.²In fact, almost 29% of Americans willstop taking their medications beforethey run out, potentially leading to aworsening of current health conditionsand/or increased health carecosts.³ Poor adherence is especiallyproblematic for pediatric patients,with an estimated 50% of childrentaking medications inadequately.⁴Noncompliance with drug therapiesalone results in an estimated $100 billionin additional health care costseach year in the United States.²

Studies have also shown thatapproximately 22% of Americans willtake less medication than was prescribed.³ Early cessation of therapymay be attributed to adverse drugreactions, resolution of patient symptoms,costs, or difficulty administeringdrugs either due to route of administration(eg, suppository), frequency ofdrug administration, complicated dosinginstructions, and/or poor palatability(particularly in children).

Incomplete therapy with antibioticscan be especially problematic, leadingto potential resistance against microorganisms,increased risk of spreadingillness to others, persistent symptoms,need for additional doctor visits/consultations,use of extra drugs, unnecessaryhospital admissions, increasedhealth care costs, and deterioration ofhealth.^5,6 Former US Surgeon GeneralC. Everett Koop once said, "Drugs don'twork if the people don't take them."²Thus, what can be done to increasepatient medication adherence in orderto enhance the successful treatmentof medical conditions?

The Resolution

Recognizing the necessity andimportance of improving outcomes,pharmacists have developed numerousmethods and devices to assistpatients with taking their medications.Over the past several decades,methods such as daily, weekly, andmonthly pill boxes, alarm clocks, postcard/telephone refill reminders, andfrequent counseling have beenemployed by many pharmacists innumerous settings to increase patientadherence. Pharmacists also havebeen instrumental in making recommendationsof combination therapiesto reduce the pill burden for patientsor therapeutic interchanges to simplifythe medication regimen and/orminimize adverse drug effects.Though these methods are ways ofreminding the patient to take his orher medication or easing the administrationof medications, they do noteliminate the problem of poor palatabilitywith many commonly encountereddrugs.

The Taste Test

Although taste is a subjective sensation,knowledge about the differencesin taste among children andadults can provide insight into whypatients may be reluctant to take certainmedications. The average adulthas approximately 10,000 taste budsthat can be found on all surfaces ofthe tongue, inside the cheek, anddown the esophagus. These tastebuds in adults are typically regeneratedevery 10 days, and the total numberof taste buds begins to decline byage 50.⁷ On the other hand, childrenhave taste buds that regenerate at amuch faster rate. They also tend tohave a much more heightened senseof taste, particularly with bitter substances.⁷ Recent evidence has shownthat genetics may also play a role inthe perception of bitter tastes.⁸

To avoid bad tastes associated withsome medications on the market,patients and/or parents of pediatricpatients will attempt to remedy thesituation themselves through refrigeration(coldness numbs the taste buds)of certain medications (eg, amoxicillin/potassium clavulanate suspensions)or mixing medications withchocolate syrup, milk, fruit juices,such as orange and grapefruit juice,and/or carbonated beverages.⁹ Patientsmay not be aware, however,that certain medications are not compatiblewith common foods anddrinks. Administration of grapefruitjuice with statins, calcium channelblockers, certain antiarrhythmics (eg,amiodarone and quinidine), proteaseinhibitors, and immunosuppressants(eg, cyclosporine and tacrolimus) hasbeen associated with increased concentrationsof these drugs, potentiallyleading to toxic levels in the body.¹⁰Taking acid-labile medications (eg,penicillin or amoxicillin/potassiumclavulanate) with acid-containingproducts, such as orange juice orother fruit juices, may reduce theeffectiveness of these drugs.Milk andeven small amounts of chocolatesyrup containing calcium can reducethe absorption of certain antibioticssuch as tetracycline and quinolones(eg, ciprofloxacin, levofloxacin, moxifloxacin)and iron supplements.

In an attempt to improve the tasteof certain medications with poorpalatability, pharmacists may add safeflavoring agents to ease patientadministration. Some pharmacistsmay not be aware, however, thatpediatric response to a medication'staste differs vastly from that of theadult. Because medications are typicallyadministered outside of a pharmacysetting, a pharmacist may notobserve or experience the strugglefaced by some parents and may overlookthe opportunity to assist withpatient adherence.

Until recently, pharmacists mayhave viewed the flavoring process aslaborious and time-consuming, due touncertainty with regard to the choiceand amount of flavoring agent to add.Companies such as FLAVORx, however,have improved the efficiency of flavoringby simplifying the methods to aquick 1-to 2-minute process for pharmacistsdespite time constraints.¹¹

FLAVORx (www.flavorx.com) offersa list of commonly prescribed medicationswith poor palatability that canassist pharmacists who may beunaware of how most medicationstaste. The unique "Wheel of Yuck" providespharmacists with flavoring recommendationsfor those drugs withpoor palatability. FLAVORx currentlyoffers 42 flavors that have all beenmedically tested for safe and effectiveuse in medications. All flavors are dye-freeand sugar-free; do not containcasein, gluten, or aspartame; are nonallergenic;contain less than 8% alcohol;and are approved by the FDA.Because FLAVORx flavors are highlyconcentrated, only a few drops arenecessary to flavor most prescriptions,regardless of medication volume.While FLAVORx is used with liquidmedications, flavors may also beadded to suspensions that have beenformulated from capsules and/ortablets by the pharmacist. To date,the FLAVORx system has flavoredover 40 million prescriptions withoutany incidence of allergy, adverse drugreaction, or reduced efficacy in themedication. Independent studies assessingFLAVORx flavors have foundan increase in compliance amongpediatric patients from an average ofapproximately 50% to over 90%.¹²

In addition to offering a variety offlavors, the FLAVORx formulary utilizesproprietary products, such asBitterness Suppressor, SweeteningEnhancer, and Vitamin/Iron MaskingAgent, to improve palatability of medicationsthat trigger a bitter or foulsensation or trigger smell receptors. Itis recommended that patients tastethe products that have been flavoredprior to leaving the pharmacy so thatchanges can be made if necessary. Inaddition, FLAVORx offers a 24-hourtechnical support system to serviceits 35,000 participating pharmaciesnationwide and answer any pharmacistor patient questions on flavoring.⁹

Along with conventional tools andmethods pharmacists have employedto improve patient adherence, flavoringis now another option that is safe,easy, efficient, and proven to increaseadherence.

Dr. Dana Brown is an assistant professor of pharmacy practice at the Lloyd L. Gregory School of Pharmacy, PalmBeach 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: ReferencesDepartment, Attn. A. Rybovic,Pharmacy Times, Ascend MediaHealthcare, 103 College Road East,Princeton, NJ 08540; or send an e-mailrequest to: arybovic@ascendmedia.com.