Pill splitting

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A pill-splitter holding a tablet ready to split.

Pill-splitting refers to the practice of splitting a tablet or pill to provide a lower dose of the active ingredient, or to obtain multiple smaller doses, either to reduce cost or because the pills available provide a larger dose than required. Many pills that are suitable for splitting (aspirin tablets for instance) come pre-scored so that they may easily be halved.

It is unsafe to split some prescription medications.

Blade (right of center) and V-shaped pill positioner.

Pill splitters[edit]

A pill-splitter is a simple and inexpensive device to split medicinal pills or tablets, comprising some means of holding the tablet in place, a blade, and usually a compartment in which to store the unused part. The tablet is positioned, and the blade pressed down to split it. With care it is often possible to cut a tablet into quarters. Also available as consumer items are multiple pill splitters, which cut numerous round or oblong pills in one operation.

Dosage uniformity[edit]

In the U.S. "uniformity of dosage units" is defined by the United States Pharmacopeia (USP), which describes itself as "the official public standards-setting authority for all prescription and over-the-counter medicines, dietary supplements, and other healthcare products manufactured and sold in the United States."[1] More than 140 countries develop or rely upon US pharmaceutical standards according to the USP.

The USP standard for dosage uniformity expresses statistical criteria in the complex language of sampling protocols. The pharmaceutical dosage literature sometimes boils this down as requiring a standard deviation in dosage weight of less than 6%, which roughly corresponds to the weaker rule-of-thumb offered for public consumption that the vast majority of dosage units should be within 15% of the dosage target. "Dosage unit" is a technical term which covers oral medications (tablets, pills, capsules), as well as non-oral delivery methods.[2]

A 2002 study of pill-splitting as conducted in four American long-term care facilities determined that 15 of the 22 dispensed prescriptions evaluated (68%) had fragment weight variance in excess of USP standards.[3]

Cost savings[edit]

Pill-splitting can be used to save money on pharmaceutical costs, as many prescription pharmaceuticals are sold at prices less than proportional to the dose. For example a 10 mg tablet of a drug might be sold for the same or nearly the same price as a 5 mg tablet. Splitting 10 mg tablets allows the patient to purchase half the number of tablets at a lower price than the same weight of 5 mg tablets.

U.S. medications suitable for pill splitting
As listed in 2002 Stanford study
Medication Drug class
clonazepam psychiatric
doxazosin blood pressure
atorvastatin cholesterol
pravastatin cholesterol
citalopram psychiatric
sertraline psychiatric
paroxetine psychiatric
lisinopril blood pressure
nefazodone * psychiatric
olanzapine psychiatric
sildenafil erectile dysfunction
* Serzone brand discontinued 2004 in U.S.

Both specialist and generalist physicians are not sufficiently aware of and do not communicate with patients about the cost to them of medication.[4]

Some potentially suitable medications[edit]

Randall Stafford of the Stanford School of Medicine published a study in 2002 of common prescription medications in the United States in which he evaluates pill splitting for "potential cost savings and clinical appropriateness". The study identifies eleven prescription medications that satisfied the study criteria, based on the American pharmaceutical cost structure, pill formulation, and dosages of the time.[5] Most of the medications listed in the table from the psychiatric drug class are antidepressants.

Uniformity of split[edit]

Not all tablets split equally well. In a 2002 study, Paxil, Zestril and Zoloft split cleanly with 0% rejects. Glucophage was described as a hard tablet, requiring significant force, causing tablet halves to fly. Glyburide exhibited very poor splitting with many splitting into multiple pieces. Hydrodiuril and Oretic crumbled. Lipitor did not split cleanly, and the coating peeled. The diamond shaped Viagra tablets made location of the midline difficult. The worst result reported was Oretic 25 mg in which 60% of tablets failed to split to within 15% of target weight.[6][7]

Alternative purpose[edit]

Some drugs have few different uses, and are usually sold in different packages and different doses for different applications. The price for some applications may be very different from that for other purposes.[citation needed] One example is Minoxidil, which is well known as a hair-growth stimulant; the same drug under the name Loniten is used for blood pressure control in much larger doses at a much lower price per unit weight.[citation needed]

Risks[edit]

Not all pills may safely be split to deliver half the dose effectively. It is safe to assume that pills scored to split easily may indeed be split, but time-release formulations and some coated pills should not be split. Pills split unevenly will not deliver accurate dosage, although small variations (e.g. within generic drug active ingredient guidelines) will usually not cause significant dosing issues.[citation needed]

Lawsuits[edit]

Timmis v. Kaiser Permanente[edit]

In a California court filing dated April 2001, Trial Lawyers for Public Justice (TLPJ) brought a class-action lawsuit against Kaiser Permanente on the grounds that "Kaiser's mandatory pill-splitting policy endangers patients' health solely to enhance the HMO's profits" in violation of the California Unfair Competition Law (UCL) and the California Consumer Legal Remedies Act (CLRA). [8] [9] In December 2004, the California Court of Appeal affirmed the trial court ruling that Kaiser's policy did not violate UCL or CLRA, noting the suit had failed to present evidence that the policy was unsafe.[10]

See also[edit]

References[edit]

  1. ^ About USP, USP web site, undated, accessed 25 Nov 2007
  2. ^ Explanatory Note: USP–NF General Chapter <905> Uniformity of Dosage Units, United States Pharmacopeial Convention, 20 April 2007
  3. ^ Rosenberg JM, Nathan JP, Plakogiannis F (2002). "Weight variability of pharmacist-dispensed split tablets". J Am Pharm Assoc (Wash) 42 (2): 200–5. doi:10.1331/108658002763508498. PMID 11926663. 
  4. ^ Alexander GC, Casalino LP, Metlzer DO. Physician strategies to reduce patients’ out-of-pocket prescription costs. Archives of Internal Medicine. 2005;165:633-636 [alexander.uchicago.edu/publications/image/.../OOPC%20mail%20survey.pdf]
  5. ^ Stafford RS, Radley DC (August 2002). "The potential of pill splitting to achieve cost savings". Am J Manag Care 8 (8): 706–12. PMID 12212758. 
  6. ^ Cross M (February 2003). "Two for the price of one beauty of pill-splitting catches on". Manag Care 12 (2): 36–8. PMID 12658856. 
  7. ^ Cohen JS (2002). "Tablet splitting: imperfect perhaps, but better than excessive dosing". J Am Pharm Assoc (Wash) 42 (2): 160–2. doi:10.1331/108658002763508443. PMID 11926659. 
  8. ^ TLPJ — Press — Timmis v. Kaiser Permanente (pill splitting) - Dec. 6, 2000
  9. ^ TLPJ — Briefs — Timmis v. Kaiser Permanente (pill splitting) - April 22, 2001
  10. ^ http://www.aishealth.com/ManagedCare/HMOLawsuitWatch/TimmisvKaiser.html