Prior administration of chocolate improves the palatability of bitter medications – The Choc-with-Med Study

INTRODUCTION
The prevailing cause for low therapeutic adherence in children is related to the poor palatability of the medicines.1 Chocolate and chocolate-based matrices have been widely used to taste mask bitter drugs in paediatric formulations.2 The aim of this study was to determine whether simply eating some chocolate before the administration of a medicine would help to mask the taste of a bitter drug in the medicine. A secondary aim was to establish whether there was a difference in taste masking efficacy between dark, milk and white chocolate.
METHOD
This was a single centre, randomized, single blind assessment of the perceived bitterness of three drug solutions. Twenty nine healthy participants aged 19-26 (62.5% female) who provided written informed consent and passed a screening test for ability to detect and differentiate the bitterness intensity of 3 quinine solutions were recruited. Quinine as bitterness standard, and flucloxacillin and clindamycin at clinical concentrations were applied as test drug solutions. Subjects were blinded to randomly receive, based on a Latin squares design, ALDI Choceur White, Milk and Dark block chocolates before self-administration of the specified drug solution. A f-point scale was used to score the bitterness of each tasting. Data was analyzed using a linear mixed effects model in the R statistical environment. The study was approved by the university ethics committee.
RESULTS AND DISCUSSION
Mean taste scores with prior chocolate administration for quinine, clindamycin and flucloxacillin were all significantly lower than control taste test without chocolate (Table 1). For quinine, there was a clear trend of dark chocolate being more effective than milk and white chocolates as a bitterness masking agent. Dark chocolate was able to negate the bitterness of quinine (score =1) in 28% of participants. All 3 chocolate types also reduced the bitterness of clindamycin and flucloxacillin, however, it is less clear which chocolate type was more effective, with all chocolate types resulting in similar mean scores for clindamycin (range 3.72–3.83) and flucloxacillin (3.38-3.45) (Table 1). A plot of predicted mean scores based on the mixed linear model, which accounts for difference in the participants, showed similar trends as the experimental data. Participants did not agree on a universal preference of a particular chocolate type to mask the taste of the 3 drugs, with higher numbers preferring dark chocolate to taste mask quinine, milk chocolate for clindamycin and white chocolate for flucloxacillin. Analysis of the ingredient contents suggest that the cocoa mass, fat and sugar contents of the 3 chocolates were all likely to contribute to the ability of the chocolates to reduce the bitterness of quinine, flucloxacillin and clindamycin.
CONCLUSION
The taste scores provided by the 29-member taste panel in this study suggest merit in taking dark, milk or white chocolate immediately before administration of a bitter medicine. This would provide a simple solution for caregivers to achieve improved medicine compliance in the paediatric population.