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Cutting Pills in Half Could Pose Problems

Pharmacists Suggest Pill-Splitting Practice Can't Be Mandated
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WebMD Health News

May 19, 2004 -- Cutting pills in half is a widely accepted strategy for lowering the cost of prescription medications, and there has even been talk by some insurers of mandating the practice for certain drugs. But a new study involving a commonly prescribed muscle relaxant suggests patients may not be getting what they think they are getting when they split pills.

In pill splitting, a doctor may prescribe a pill with double the needed dose of medication, telling the patient to split the pills and only take half of a pill. This doubles the amount of medication the patient purchased, thereby saving the patient money.

Researchers found that uneven tablet splitting resulted in varying dosages of the split pill, ranging anywhere from 50% to 150% of appropriate levels. Researchers say this occurred regardless of whether a commercial available pill splitter or a kitchen knife was used to cut the pills.

Pharmacy professor Thomas Cook, PhD, who led the study, tells WebMD that while pill splitting may be an acceptable practice in certain situations, it could easily lead to problems if used on the wrong drug or for the wrong patient.

"You may realize a cost savings in terms of the price of the drug, but there are also questions of efficacy and safety when people don't end up taking the prescribed dosage of a drug," he says.

Pharmacists Weigh In

The nation's largest professional association of pharmacists addressed the practice of pill splitting in an advisory released Wednesday.

"What looks like a no-brainer cost-saving approach isn't right for every product or for every patient," the statement from the American Pharmacists Association (AphA) read. "The decision of whether or not to split tablets must consider both the product and the patient."

AphA Vice President Susan Winckler says pills that are scored -- designed to be cut -- are naturally better candidates for splitting than pills that are not scored.

The drug used in Cook's study, McNeil Pharmaceutical's muscle-relaxant Flexeril, is not scored and also has a film coating that makes it especially hard to split. When researchers cut 10 mg tablets in an effort to produce two 5 mg pills, they ended up with dosages ranging anywhere from 2.5 mg to 7.5 mg.

In addition to features of the individual medication, patient characteristics -- such as dexterity, visual and mental acuity, and the number of other medications being taken -- have to be factored into the decision of whether to split pills, Winckler says.

"If this is something the consumer is comfortable with, it can work well with certain medications," she tells WebMD. "But something that can be appropriate should never be assumed to always be appropriate."

Savings Potential 'Huge'

Stanford University professor of medicine Randall Stafford, MD, PhD, agrees but adds that the cost benefits would be enormous if doctors embraced the practice more often when appropriate.

In a study published two years ago, Stafford and colleagues found that doctors participating in a Massachusetts-based health plan rarely recommended pill splitting, even though it was in their economic interest to do so.

Researchers identified 11 commonly prescribed drugs they considered appropriate candidates for splitting, but found that just 2% of the potential savings from splitting these drugs were actually being realized.

"This is a very attractive option for people who are paying for their medications out of pocket, especially if they are taking many different medications," he tells WebMD.

For example, 30 tablets of the widely prescribed antidepressant Zoloft sold for $72.99 on the online pharmacy Drugstore.com Wednesday in both 50 mg and 100 mg doses. Splitting 100 mg tablets could save someone taking a 50 mg daily dosage $36.50 a month or almost $450 a year.

"There are certainly patients for whom this is not an appropriate option, so I would never favor mandating this," Stafford says. "But the unrealized potential savings are huge."

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