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Health Care Hot Topic: Tablet Splitting

Created 07.25.07 by Sarah M. Lawrence
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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

 

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Comments

  1. cassandra says:

    interesting

  2. Lin says:

    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.

  3. Chris says:

    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???

  4. Sarah M. Lawrence says:

    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.

  5. AJ says:

    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.

  6. Sarah M. Lawrence says:

    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.

  7. Anna, CPhT says:

    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.

  8. Al says:

    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

  9. Sarah M. Lawrence says:

    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.

  10. GregRph says:

    Generic Toprol xl 25mg. It is extended release and the tablet is scored.

  11. FuturePharmD says:

    I take levoxyl and it is more consistent if I don’t split it.

    Interesting, education sounds like the key.

  12. Flopotomist says:

    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.

  13. frescanese says:

    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 :) )

  14. Susan says:

    So is it ok or not to split Augmentin?

  15. Bill says:

    It has been suggested, that the VA, in requiring split pill prescriptions has been a VA cost saving measure. This may be true. However, at the same time veterans that are required to split their pill prescriptions are being over-charged. This practice is contrary to what is described in the Federal Register of 12/6/2001. The regulation states that veterans are not required to pay an amount in excess of the actual cost of medication and pharmacy administrative costs related to the dispensing of the medication.
    =
    Pill medication is dispensed as shown in the following example. VA prescriptions are normally dispensed in supplies of 90 days. However, to explain these over-charges by the VA in violation of 38 USC 1722A, this example will be at it’s simplest and most understandable. Let’s say that you (veteran B), are at the VA dispensary standing in line getting your prescription. Veteran (A) in front of you is dispensed the exact same prescription. Her copay for a 30 day supply of 30 pills is $8.
    =
    You, (veteran B) having the same exact dispensed prescription supply of 30 pills,
    being that your condition is not as severe, your prescription requires that you to split this 30 pill ($8) supply. After you sit down at your kitchen table and split your 30 pill supply, you now have 60 split pills, a 2 month supply. But hold on! Except your co-payment cost for the same exact dispensed 30 pill, $8 supply, now that it has been split, has increased in cost. It now carries a co-payment of $14.
    =
    The United States Code contains a consolidation and codification of the general and permanent laws. “38 USC 1722A (a)(1) Subject to paragraph (2), the Secretary shall require a veteran to pay the United States $8 for each 30-day supply of medication furnished such veteran under this chapter on an outpatient basis for the treatment of a non-service-connected disability or condition.” However, until we can get past the cost for the same exact dispensed $8 pill medication, as explained in paragraph (2), of 38 USC 1722A, “The Secretary may not require a veteran to pay an amount in excess of the cost to the Secretary for medication described in paragraph (1),” and as well, the Federal Register, forget what it says about 30-day supply.
    =
    Title 38 USC 1722A, paragraph (1) codification is clarified by the Federal Register 12/6/2001 Final Rule, as to the actual cost in dispensed supplies “Also, under 38 USC 1722A, VA may not require a veteran to pay an amount in excess of the actual cost of the medication and pharmacy administrative costs related to the dispensing of the medication. VHA conducted a sturdy…and found that VA incurred a cost of $7.28 to dispense an outpatient medication even without the consideration of the actual cost of the medication…Under these circumstances, we believe that a $7 copayment would not exceed VA’s cost.” [Present day copayment now $8.]
    =
    Published in the Federal Register, which provides a discussion of the background and the need for the regulation, and in case of a final rule how it differs from the proposed rule.
    =
    This should explain why veterans’ have continued to be, and have been overcharged by the VA since 2002.
    =
    This claim is now before the United States Court of Appeals for Veterans’ Claims.

  16. Victor says:

    This study seems sound, but it’s measuring the wrong things. If “the concerned practitioner may wonder: is this safe and effective for patients? Does the financial benefit outweigh the potential for adverse therapeutic outcomes?” then you would measure what patients are actually doing, and we know some people just take a double dose every other day without splitting. Dangerous. Whether the pill can be split effectively is missing the point, some people just don’t split.

    Can we think of any other consumer industry that would get away with asking end-users to do this? The only reason insurance companies can get away with it is because their clients are corporations, not consumers. It’s this sort of practice that makes people angry enough to reform the industry at the Federal level.

  17. Bill says:

    The question of excessive copay for VA split pill prescriptions has been settled. Even though the VA mentions their concern for “reasonable charges.., billings practices closer to industry standard charge structures and billing practices”, and the question of “actual cost of dispensing” , veterans will continue to be overcharged for spilt pill prescriptions. The United States Court of Appeals for veterans’ Claims has made their ruling. A two(2) to one(1) decision. Judge Hagel, dissented, and accordingly, found the ruling, “..arbitrary, capricious, an abuse of discretion, or otherwise not in accordance with the law.” and filed a separate opinion. His comments, in brief follow.

    UNITED STATES COURT OF APPEALS FOR VETERANS CLAIMS.
    NO. 09-112 (Decided April 11, 2011)

    “HAGEL, Judge, joins, concurring in part and dissenting in part: I concur with the majority’s
    conclusion that the plain and unambiguous language of 38 U.S.C. § 1722A(a)(1) requires a veteran
    to pay a full copayment for a 30-day supply of medication, without regard to the dosage or number
    of pills prescribed to the veteran. I write separately, however, to express my disagreement with the
    majority’s conclusion that the phrase “cost to the Secretary for medication,” as used in section
    1722A(a)(2), is susceptible to more than one interpretation.”

    “When a pure question of law, such as the interpretation of a statute, is at issue, the Court
    reviews the conclusions of the Board de novo, without deference. Smith v. Gober, 14 Vet.App. 227,
    230 (2000). As explained above, after reviewing the language of section 1722A, I would conclude
    that the plain and unambiguous language of subsection (a)(2) prohibits the Secretary from requiring
    a veteran to pay an amount in excess of the cost to the Secretary for each 30-day supply of
    medication furnished to him or her, without regard to the administrative costs incurred by the
    Secretary in actually dispensing such medication. I would therefore conclude that the Board’s
    interpretation of that provision was arbitrary, capricious, an abuse of discretion, or otherwise not in
    accordance with the law. See Kent v. Principi, 389 F.3d 1380, 1384 (2004) (holding that the
    “arbitrary, capricious, an abuse of discretion, or otherwise not in accordance with the law” standard
    of review “contemplates de novo review of questions of law”). Accordingly, I would set aside the
    Board’s December 2008 decision to the extent that it concluded that the appellant’s copayment was
    not excessive under section 1722A(a)(2) and would remand the matter for further development and
    readjudication consistent with a proper interpretation of section 1722A(a)(2).

    Lastly, I understand that some might say that the interpretation that I express would place
    an unnecessary accounting burden on VA. The calculation that I believe the statute requires VA to
    make in these instances is, however, routinely made up front by private pharmacies when
    determining the profit margin sought on each drug dispensed to their customers. Thus, I do not
    believe that such a calculation places an unreasonable burden on VA. As a result, I do not believe
    that my interpretation of section 1722A produces an absurd result”.

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