Health Care Hot Topic: Tablet Splitting
Created July 25, 2007 by Sarah M. Lawrence
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:
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
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