Tablets – To Split or Not to Split?

by on July 29, 2009

The FDA recently issued a consumer update about tablet splitting, warning that it might not be a good idea.  They tell consumers that splitting tablets is a bad idea because: one might get confused about the correct dose, equal distribution of medicine in split tablets is questionable, some tablets are hard to split and not all pills are safe to split.

They go on to say that talking to your pharmacist or physician is important before splitting a tablet.

While the FDA information is correct, I think tablet splitting is actually a way pharmacists can help their patients. In these economic times, a $30 co-pay (not to mention some of the $100 drugs) can mean a lot.  We can save patients money by splitting a Lipitor, and that means they’ll be more likely to take the drug and not skip doses to save money.

So, what can we do? I read one suggestion that all pharmacists should split the tablets for the patients.  Most retail outlets can’t really afford the time it takes to split pills for patients.  I also think that if you’re splitting hundreds of pills a day, you’ll probably be less accurate & more hurried than most patients at home.

I do think that for “split” prescriptions, the pharmacist should spend a little extra time counseling the patient, perhaps direct them to a pill splitter for purchase (they’re around $3-5, well worth it) and explain the importance of splitting the pill correctly, etc.   I think we do a good job of that already.

Does counseling matter? It depends.  A study was conducted where half the participants were given instructions on how to split the pills and the other half was not.  They were given various shapes of pills to split.   In the end, regardless of group, researchers found patients’ tablet-splitting resulted in dosage deviations between 9 percent and 37 percent from those intended. Those with experience, regardless of instruction, were most accurate at splitting flat, round tablets. More deviations in dosage were found with the more irregularly shaped pills.  To me, this says that maybe the pharmacist should actually observe the technique and give pointers, since doing seems more important than telling.

Another major issue is that the pharmacist doesn’t always know if the pill is to be split.  For insurance purposes (and this is fraud, but it happens), some prescriptions for tablets that are intended to be split are written as “1 daily.”  The doctor assumes the patient will remember.  It is up to the patient to ask the proper questions in that case.  I always tend to counsel on “splitting,” especially when I think the pill might be split or when it is important NOT to split a tablet.

I’ve even encountered some patients splitting their pills on their own when they weren’t instructed to do so.  For example, the physician prescribed 40mg of Lipitor but Mr. Smith thinks 20mg is just fine and it is  much cheaper to get every other month.

I wish we all had time to do drug reviews and say, “Mr. Smith only picks up his Lipitor every other month. What gives?” and then sit down and talk to him, but we don’t.  Wouldn’t it be great if our computer systems could pick out those trends? Maybe someday.

There needs to be transparency on the part of the patient’s and the doctors (and insurance companies are a major problem).  I think the more “warnings” we issue about the topic, the more patients are going to be afraid to talk about it.  What if they tell the pharmacist that the pill is going to be split and they won’t do it?  What if they call the insurance company?  This shouldn’t be a patient’s dirty little secret.  We should encourage patients to discuss any issues they have.  If we do notice those types of trends, we should bring up the topic.  Mrs. Smith could split an 80 mg tablet and get the dose he needs for the same price.

Even a simple handout about the benefits of splitting drugs and “talk to your pharmacist” could encourage transparency and proper technique.

Here’s some info on what you can and cannot split: