Health Care Hot Topic: Tablet Splitting
Posted on July 25, 2007
Filed Under Health Care Policy and the Student Doctor, Pharmacy (PharmD)
Adapted by Sarah M. Lawrence
Used with permission
Tablet splitting has become a popular method for controlling prescription drug costs. Many insurance companies offer free tablet splitters or other incentives to convince patients to purchase higher strength tablets and take a half tablet per dose. With the practice on the rise, the concerned practitioner may wonder: is this safe and effective for patients? Does the financial benefit outweigh the potential for adverse therapeutic outcomes?
In a letter to the editor of the Journal of Clinical Psychology, two pharmacists with the Department of Veterans Affairs in Louisville, Kentucky examined the issue using split doses of the anti-depressant sertraline:
Dear Sir:
Some pharmaceutical companies price all strengths of a particular medication the same. Medications may also be priced so that one larger tablet is less expensive than 2 tablets equaling the same dose. Many tablets are scored for breaking or are easy to cut using commercially available tablet cutters.
The Department of Veterans Affairs Medical Center and managed care organizations use tablet splitting as a cost-containment measure. For example, a prescription for 10 mg of simvastatin is filled with 20-mg tablets and a pill cutter. Lisinopril, citalopram, metoprolol and sertraline are medications that are commonly split. If is a patient is unable to split tablets, then they are not required to do so.
Concern has been raised regarding the accuracy of the delivered dose of the antidepressant sertraline after splitting the tablets. Since this is one of the medications routinely split, we wanted to determine if tablet splitting caused wide fluctations in the daily dose.
About the Study
Methods: the authors used 5 volunteers, ranging in age from 32 to 77 for this pilot study. Each volunteer received brief verbal instructions on spliting the tablets along with a supply of tablets and a tablet cutter. Each tablet was individually weighed and split (either manually or by tablet cutter). Each resulting piece was then weighed and the results recorded.
Results: the authors found that the amount of sertraline in the split tablets was acceptable and evenly distributed with very little sertraline (0.55%) lost in the splitting process. All tablet pieces were appropriately sized and usable after splitting.
Discussion: Sertraline has a long elimination half life (25-26 hours). This long half life allows overlap of the daily doses and maintains acceptable blood levels despite potential variations in the split dosage form. The authors also suggested that taking the two pieces from one split tablet on consecutive days would also help minimize potential fluctuations.
As the authors continued in their letter to the editor:
Tablet splitting is effective for reducing pharmaceutical cost and has been used successfully in appropriate patients.
Counseling on how to use a tablet cutter may decrease dosage variance.
Paul R. Matuschka, PharmD
James B. Graves, PharmD
VA Medical Center
Louisville, KY
Action Steps for Practitioners
- Be aware of the potential for cost-savings from tablet splitting.
- Consider tablet splitting for appropriate patients.
- Know which medications are appropriate for splitting and which are not.
- Provide patients with an appropriate tablet cutter.
- Educate patients on proper tablet splitting practices.
About the authors:
James B. Graves is chief of the Pharmacy Service at the Louisville VAMC.
Paul R. Matuschka is pharmacy clinical manager at the Louisville VAMC.
Sarah M. Lawrence is a pharmacy student at the University of Kentucky, currently assigned to the pharmacy service at the Lousville VAMC.
Reference: Journal of Clinical Psychology 62:10
If you would like to discuss this article please visit the discussion thread located here:
http://forums.studentdoctor.net/showthread.php?p=5413862#post5413862
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13 Responses to “Health Care Hot Topic: Tablet Splitting”
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interesting
I split my tablets and capsules all the time. I have insurance, and this lets me have extra medication when needed by doubling or tripling the amount I normally need per refill.
What we need is a list of pills we shouldN’T split. I used to do this with our indigent care patients in the hospital I did my med school clinicals in. But since the attending didn’t know for sure if most pills were okay to split or not, we used this less than we should’ve. I remember doing online research at the time and seeing that coumadin was questionably bad to split…and that’s DEF a med we don’t want to screw around with. So does anyone know of more meds that r bad to split???
Some dosage forms should never be split: capsules, enteric-coated tablets, sustained, controlled or extended-release tablets, and tablets that combine two drugs in which one dose increases with tablet size but the other does not increase at the same proportion (like Augmentin).
A physician or anti-coagulation pharmacist may at times direct patients to split coumadin in order to adjust the dose based on INR results. But patients should never do this on their own.
This isn’t a “med” technically, but there was a paper in our schools newspaper about the dangers of “splitting” caffeine pills. The reason being that the protective coating of the pill is nullified and the contents are released too quickly then intended and could result in problems.
Caffeine is definitely a drug product. Anything with a protective coating should never be split, chewed or crushed. It’s important to be educated about these issues so we can educate patients.
Sertraline?? Oh come on! I’m glad they did a study. If someone takes 49 mg instead of 50 mg, it won’t make a freaking bit of difference. Hell, if they take 40 one day and 60 another, I’ll bet the average patient wouldn’t even notice.
Technically, extended based products that are wax based are usually ok to split. You just have to know the underlying technology in the tab of interest
Al,
That may be true but that defeats the purpose of the extended release dosage form. Once it’s split it becomes immediate release. And that may deliver a higher than optimal dose of medication to the patient immediately vs. over time as intended.
Generic Toprol xl 25mg. It is extended release and the tablet is scored.
I take levoxyl and it is more consistent if I don’t split it.
Interesting, education sounds like the key.
The problem not addressed here was the concern that patients with movement disorders, arthritis, or other challenges to the mechanics of the pill splitter may be forced into struggling with the device in order to get their dose.
The physician, and NOT some HMO or pharmacist should have the final say in whether or not the patient gets a 10mg tablet or a 20 mg tablet with instructions to split it.
Flopotomist brings up a good point.
Another example: one of our patients with schizophrenia was discharged with a script requiring he take 3.5 tablets per day. For a syndrome with such inherent adherence problems, this seems like a dangerous practice.
Just a thought: does anyone know what percentage of patients actually take their prescribed meds? (I don’t know and it seems like too much work to pubmed it
)