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EDUCATING PHARMACY TECHNICIANS FOR SUCCESS:
UNDERSTANDING CURRENT ISSUES IN
PEDIATRIC MEDICATION ADHERENCE
Objectives
 Understand the common barriers to medication adherence
 Discuss implications of poor medication adherence
 Review the anatomy and physiology of taste
 Identify how taste can impact medication adherence
 List common medications associated with poor palatability
 List considerations for flavoring medications in clinical practice
 Explain the importance of choice and patient preferences with regards to medication adherence
 Explain how flavoring can improve the patient medication experience and ultimately improve
medication adherence
Adherence
Adherence
“Patient adherence ~ the extent to which a person's behavior- taking
medication, following a diet, and/or executing lifestyle changescorresponds with agreed recommendations from a health-care provider.”
Source: Sabate E, ed. Adherence to long-term therapies: evidence for action. Geneva, World Health Organization, 2003.
Adherence
Pediatric non-adherence is a major concern for many reasons
 Continued disease processes
 Spread of illness
 Slower recovery
 Health complications
 ER visits /Hospitalizations
 School/Work absenteeism
 Antibiotic resistance
 Costs incurred by additional
doctor visits and therapeutic
drug changes
don’t
Drugs don’t“rugs
work in
patients work
who don’t
take
in patients
them.
who don’t take
C. Everett Koop
them.”
~ C. Everett Koop
Adherence
Several factors that contribute to poor adherence
 Duration
 Schedule
 Formulation
 Taste and Palatability
 Cost
 Adverse effects of medication
 Cultural beliefs about illness and
medication
 Illiteracy or language barriers
 Lack of family or social support network
Studies suggest that
Studies suggest that
adherence
for
adherence
rates forrates
pediatric
pediatric
medications
aremedications
typically
between 50-60%.
are typically
between 50-60%.
!
Adherence
The heart of the problem
Until a child is around 8 years old,
swallowing pills can be challenging. This is
often due to the smaller structure of a child's
esophagus. Therefore, children under the
age of 8 are typically prescribed liquid
medications.
While liquids are easier to administer, getting
the child to swallow is whole different story.
For the pediatric population, taste and
poor palatability are identified among the
most significant barriers to adherence.
Focus group and nationwide studies show:
79%
7 in 10
of children complain about
bad tasting medication or
taste that is too “yucky.”
parents report a moderate
to severe struggle giving a
child medicine because of
how it tastes.
Adherence
Special considerations
 While it may seem the child is being difficult, this rejection is rarely the
result of a child’s desire to be picky or fussy. Rather, it is an actual physical
inability to swallow an unpalatable substance.
 Children have a greater number of taste buds than adults. These taste
buds regenerate every two weeks. As with many of the senses, taste
becomes altered as a function of the aging process. That explains why
most children find certain flavors to be too 'strong' when adults do not.
 Children, and infants in particular, are most sensitive to bitter and sweet
tastes, making them less likely to swallow bitter-tasting medications and
also more prone to liking sweeter, fruity flavors.
 Unfortunately the active ingredients in many medications often taste
bitter and/or have a pungent smell. Masking the taste of these
medications can often be difficult simply because the innate flavor is so
overpowering.
Anatomy &
Physiology of Taste
Anatomy & Physiology of Taste
At this point its probably
helpful to review the
physiology of taste,
to better understand the
biological basis for these
underlying problems.
Studies suggest that
adherence rates for
pediatric medications
are typically
between 50-60%.
!
Anatomy & Physiology of Taste
Taste is a chemical sense.
• Provides information on chemical composition of food.
• Acts as final safety checkpoint prior to consumption.
• The body’s mechanism developed to recognize foods needed for nutritional value, as well as a natural defense
mechanisms helping to identify harmful substances.
• For example, bitter flavors are more commonly associated with natural toxins, where sweet tastes are
associated with energy rich foods needed for survival.
Flavor is the culmination of sight, taste, touch and smell.
Anatomy & Physiology of Taste
Sweet
provides a recognition of energy rich nutrients
Salty
allows modulating the diet for electrolyte balance
Sour
typically indicates the presence of acids and allows
for the detection of when foods may be spoiled
Bitter
allows sensing of diverse natural toxins
Umami (savory)
it is the taste of amino acids (e.g. meat broth or
aged cheese).
Studies suggest that
adherence rates for
pediatric medications
are typically
between 50-60%.
!
Anatomy & Physiology of Taste
Variation in taste perception
 Many diagrams present “taste-zones,” however it is now believed that while there are
differences to taste sensitivity around the tongue, the different tastes are perceived in any
area taste buds exist.
Studies suggest that
!
adherence rates for
 Presence and density of taste buds may be different individual to individual
pediatric medications
• Super-tasters, normal tasters, non-tasters
are typically
• Age variation
 Additional patient-specific factors influencing taste:
• Concurrent disease states
• Concurrent medications
• Cultural factors
• Environmental factors
between 50-60%.
Anatomy & Physiology of Taste
Variation in taste perception
 It is estimated that 25% of the population are super-tasters, indicating a higher
density of taste-buds and increased sensitivity to certain tastes.
Studies suggest that
 Women, as compared to men, are more likely to be super-tasters.
adherence rates for
 Normal-tasters make up 50% of the population, and non-tasters the remaining 25%.
pediatric medications
 Non-tasters are less effected by strong flavors.
are typically
 Research indicates a decline in the number and change in the shape of taste buds
between 50-60%.
with age.
 Age related decline in taste is more often correlated to co-morbidities affecting smell,
which in turn can impact an individuals sensitivity to taste.
 Additionally, certain disease states, medications, dental work, as well as cultural or
environmental factors may influence taste sensitivity and preference.
!
Medications, Taste,
& the Role of Flavor
Medications, Taste, & the Role of Flavor
 Research supports taste as being a significant factor in adherence and
recognizes that this issue should be considered when selecting medications, especially
Studies suggest that
among pediatric patients.
adherence rates for
pediatric medications
 The chemical structure of a medication determines not only the pharmacological
are typically
efficacy of a drug but the bitter taste as well. In a recent article “Helping the Medicine
between 50-60%.
Go Down,”Dr. Julie Menella, a researcher from the Monell Chemical Senses Center
stated “The number one reason for non-compliance among children when taking
medicine or eating vegetables is that they don't like the taste.”
!
 Earlier we addressed the fact that rejection of bitter flavors is part of basic biology.
Bitter flavors are most commonly associated with natural toxins and poisons.
Rejection of such tastes is thought to have evolved to protect the consumer from harm.
Medications, Taste, & the Role of Flavor
 A substantial number of liquid medications are dispensed each year, many of which are
associated with poor palatability.
Studies suggest that
adherence rates for
 While companies recognize palatability issues with medication administration, often
pediatric medications
only one flavor per formulation is manufactured. This is primarily due to Research and
are typically
Development costs as well as production costs.
between 50-60%.
!
 Having the ability to change the flavor of medications to improve palatability as well as
meet patient preference can increase adherence and improve the overall patient
experience.
Medications, Taste, & the Role of Flavor
The unpleasant experience
“Many parents are faced with the daily challenge of getting their children to take a medication. The unpleasant flavor of the medicine
can thwart the benefits of even the most powerful drug, and failure to consume medication may do the child harm, and in some cases
may be life-threatening.”
Julie Mennella of Monell Chemical Senses Center
Like most of us, children will resist unpleasant experiences.
Medications, Taste, & the Role of Flavor
The unpleasant experience
 It is a vicious cycle that all begins with an unpleasant tasting
medication and a hesitant child.
 Consequently, medicine-time becomes a stressful and
unpleasant experience for parents and children.
 Struggling with or forcing a child to take an unpleasant tasting
medication adds additional strain to the already unpleasant state of
feeling sick.
 It can also predispose children to believe that all medications,
regardless of taste or smell, are unpleasant, giving them a
negative impression of all medicinal treatments.
 Oftentimes a parent's frustration with administering a bad tasting
medication will cause them to stop treatment as soon as their
child’s symptoms go away, thus not completing the full course of
medication as prescribed by their physician.
Medications, Taste, & the Role of Flavor
Coping with the stress of taking medication
Arguments about taking medication, kicking, screaming, and spitting
become part of a daily struggle for parents trying to get their children
to take their medication.
To lessen the stress and anxiety of taking medications, parents have
resorted to improving palatability through refrigeration, or by mixing
medications with milk, juice, soda, or syrup.
Unfortunately, these “home remedies” can compromise the
stability, efficacy, and potency of many liquid medications.
A more feasible option is to have a liquid prescription flavored at a
local pharmacy.
Flavoring is a safe and effective solution that not only helps
mask the unpleasant taste of a medication, but also customizes
the medication to satisfy an individual child’s taste preferences.
Medications, Taste, & the Role of Flavor
The role of flavoring medications
 Flavoring circumvents limitations in single-flavoring options available.
 Provides choice to children in the flavor of their medication.
 Provides a method to ensure the 1st line therapy is used, even when taste is a potential
barrier.
 Offers an opportunity to improve adherence issues related to taste.
 Provides individualization of care.
Medications, Taste, & the Role of Flavor
The role of flavoring medications
 Manufactured medications come pre-flavored, however flavoring systems offer the opportunity to
modify the medications taste to not only improve palatability but also to tailor the medication to the
patients’ taste preference.
 Flavoring medication offers parents and prescribers the opportunity to incorporate the child and his or her
taste preference in taking medication, “offering children a choice in a no choice situation.”
 The ability to flavor medications offers the pharmacist the opportunity to individualize the medication to
the patient, recognizing that taste is not one-size fits all in medicine.
 Studies have demonstrated that improving the taste of medications leads to improved adherence among
pediatric patients, which has significant implications for clinical outcomes.
 Finally, it may reduce the parent/caregiver stress of administering medication when the child’s choice
for flavor is incorporated.
Medications, Taste, & the Role of Flavor
Less stress, more delight
7/10
Studies suggest that
adherence rates for
Americans now report “stress” as their #1 health concern.
60% of parents
pediatric medications
say medicine-time
are
typically
 Offering mom and dad a solution to what is normally a high
with their kids is
between
50-60%.
highly
stressful
stress situation elevates their pharmacy experience to a higher
level. Most parents will be surprised to learn that custom
flavoring their child’s medication is even an option.
 Flavoring leaves a lasting impression because it makes medicine-time so much easier.
 With less stress comes more delight. More delight translates to happy patients and loyal
pharmacy customers.
!
Medications, Taste, & the Role of Flavor
Children taking charge
 Not surprisingly, children embrace pleasant experiences, including pleasant
tastes.
 Flavoring not only helps mask the unpleasant taste of a medication but
also customizes the medication to satisfy the individual child’s taste
preferences.
 Studies have shown that allowing a child to play an active role in choosing the
flavor of their medication makes him/her more compliant to drug regimens.
Showing a child that they have the capability to modify the flavor of a medication
to a flavor of their liking grants them some authority in their treatment.
 Allowing them to choose how their medication will taste encourages a
child to take charge of their own health and is yet another way to promote
adherence.
Medications, Taste, & the Role of Flavor
Flavoring can help!
The addition of a safe pharmaceutical
flavoring to medicine can greatly improve a
child's sensations of taste and smell, leading
to acceptance and therefore adherence. In
fact, studies show that proper flavoring can
increase adherence in children from 53%
to over 90%.
As a pharmacist or technician, simply
recommend a product like FLAVORx when
dispensing a child's medication. The process
is scientifically-proven, safe and effective.
Unlike the addition of food or drink, FLAVORx
flavoring available at the pharmacy will
not adversely affect a medicine's stability,
efficacy, or potency.
Medications, Taste, & the Role of Flavor
When flavoring medications…
Consider patient
age and taste
preference
Medication “tastes”
may fit best with
certain flavorings
Flavoring agents
commonly used
Simple syrup
Ora-sweet, Ora-blend
Fruit flavored syrups (cherry, orange, etc)
Commercially available flavoring agents
(FLAVORx)
Medications, Taste, & the Role of Flavor
When flavoring medications…
 Patient age and taste preferences should be considered when choosing what flavor to add to medications. Younger patients are more likely to prefer
sweeter flavors, as compared to older patients.
 Important to consider the type of medication to be flavored as certain flavors may be better at masking bitter medications versus sour medications.
 Traditional approaches to flavoring medications have included the use of simple syrups, ora-sweet syrups or even masking in fruit and chocolate
flavored syrups.
 FLAVORx is a commercially available flavoring system that is commonly used by retail pharmacies in flavoring both compounded and manufactured
medications.
Medications, Taste, & the Role of Flavor
Examples of medications with poor palatability
 Acetaminophen with codeine elixir
 Albuterol liquid
 Amoxicillin/
clavulanic acid suspension
 Azithromycin suspension
 Clarithromycin suspension
 Cefuroxime suspension
 Cephalexin suspension
 Dexomethorphan syrup
 Erythromycin liquid
 Erythromycin and
sulfisoxazole suspension
 Iron Liquid
 Loratadine suspension
 Nitrofurantoin suspension
 Phenobarbital elixir
 Prednisolone syrup
 Ranitidine syrup
 Sulfamethoxazole/
trimethoprim suspension
 Vitamin liquids
Medications, Taste, & the Role of Flavor
Pairing medications with flavor
BITTER
 Acetaminophen
 Amoxicillin/
Clav acid
 Cimetidine
 Cefuroxime
 Erythromycin/
Sulfisoxazole
 Fluoxetine
 Haloperidol







Loperamide
Metronidazole
Naproxen
Penicillin
Risperidal
SMZ/TMP
Theophylline
FOUL
 Cephalexin
 Clindamycin
 Ferrous Sulfate
 Polysaccharide-iron
complex
SALTY
 Potassium Chloride
 Sodium Fluoride
 Peridex
 Citrate Magnesia
 Bi Citra or Poly Citra
Medications, Taste, & the Role of Flavor
Pairing medications with flavor
For medications which
are bitter tasting, grape
and bubblegum flavors
have been shown to be
the most successful at
masking these flavors.
For foul tasting medications
such as clindamycin, the use
of oil based flavors such as
lemon, orange and raspberry
produces the best result.
For salty flavors,
grape and raspberry
appear to work the
best.
Something to keep in mind- for medications with more potent tastes, increasing the concentration of sweetener
is more likely to produce a better product versus increasing the concentration of the flavoring agent.
Medications, Taste, & the Role of Flavor
The customer experience and flavoring
 One of the most impactful ways to generate a positive customer
experience is through customization – giving customers the
feeling of personalization and control.
 There is no easier way for your pharmacy teams to accomplish
this than through taste customization using a product like
FLAVORx.
 With a wide-assortment of flavors to choose from, your customers
can tailor the taste of their liquid prescriptions
and OTC medications to their favorite flavor.
 Flavoring is a powerful way to create a lasting positive
experience with your customers which in turn builds brand loyalty.
 By providing a choice of flavors, no matter what medication is
being dispensed, you’re providing excellent customer service
and increasing the likelihood of higher prescription adherence.
What could be better than that?
Medications, Taste, & the Role of Flavor
Promoting the flavoring service
Promoting the flavoring service to your customers can be fun and
easy. You’re providing a valuable service to parents who, at the
very least, appreciate you giving them the option to have the
medication custom flavored.
We’ve heard from countless parents who say they love the
service and are so thankful their pharmacy recommended it.
On the flip side, we also hear from more parents than we’d like to
admit who are so frustrated by the fact that flavoring wasn’t
mentioned by anyone when they dropped off or picked up the
prescription.
The fact is, there are a whole bunch of moms and dads out there
who want to know about custom flavoring for their child’s medicine.
So tell them about it!
Medications, Taste, & the Role of Flavor
Future issues in flavoring
 Research continues to identify factors that may
assist in predicting taste preferences.
• Trying to determine the role genetic
factors may play in predicting taste
preference.
 Continued research in the role of flavoring to
improve patient adherence and health
outcomes.
• While initial studies have shown positive
results on medication adherence resulting
from interventions using flavoring to mask
taste, continued research is necessary.
Medications, Taste, & the Role of Flavor
Future issues in flavoring
A Pediatric Formulation Initiative was established to improve pediatric formulations.
• The issue of palatability with respect to pediatric medications has also been recognized as an area for national
focus. The Best Pharmaceuticals for Children Act of 2002 led to the Pediatric Formulation Initiative (sponsored
by the Eunice Kennedy Shriver National Institute of Child Health and Human Development NICHD) which is
focused on addressing the lack of appropriate medication formulations for children.
Continued efforts are ongoing in identifying new methods to improve the ease of medication administration.
Concluding thoughts
 Medications successfully taken because of flavoring are far less
physically, emotionally, and financially exhausting.
 For children, taste and choice may be the only motivation to take a
medication and complete a full treatment program.
 Improving the taste of a medication and allowing patients to choose
how their medication will taste can improve therapy adherence, leading
to both improved clinical and economic outcomes.
 Medication adherence is a major concern in the realm of healthcare.
And, now YOU have a solution!
Medication Flavoring Options
Here is an additional list of Compounding/ Medication Flavoring Supply Companies :
Apotheca Supply, Inc.
3220 Highway 31 South Decatur, AL 35603
256-350-2347
FAGRON
2400 Pilot Knob Road Saint Paul, MN 55441
651-681-9517
FLAVORx
9475 Gerwig Ln Columbia, MD 21046-2882
800-884-5771
Galenova Inc
4555 Beaudry St-Hyacinthe CANADA
450-778-2837
Gallipot, Inc.
2400 Pilot Knob Road, Saint Paul, MN 55441
800-423-6967
Medisca
661 Route 3, Unit C, Plattsburgh, NY 12901 USA
800-932-1039
Naturally Vitamins/ Marlyn Nutraceuticals
4404 E Elwood St Phoenix, AZ 85040-1909
480-991-0200
Professional Compounding Centers of America (PCCA)
9901 S. Wilcrest Dr. Houston, TX 77099
281-933-6948
Contact
ContactUs
us
FLAVORx, Inc.
9475 Gerwig Lane, Columbia, MD 21046
P: 800-884-5771
[email protected]
F: 240-223-1099
www.flavorx.com