The practice and clinical implications of tablet splitting in international health

Ivo Elliott,Sue J Lee,Sengchanh Yeuichaixong,Mayfong Mayxay,Paul N Newton

doi:10.1111/tmi.12309

Abstract

ObjectiveTablet splitting is frequently performed to facilitate correct dosing, but the practice and implications in low-income settings have rarely been discussed.MethodsWe selected eight drugs, with narrow therapeutic indices or critical dosages, frequently divided in the Lao PDR (Laos). These were split, by common techniques used in Laos, by four nurses and four laypersons. The mean percentage deviation from the theoretical expected weight and weight loss of divided tablets/capsules were recorded.ResultsFive of eight study drugs failed, on splitting, to meet European Pharmacopoeia recommendations for tablet weight deviation from the expected weight of tablet/capsule halves with 10% deviating by more than 25%. There was a significant difference in splitting accuracy between nurses and laypersons (P = 0.027). Coated and unscored tablets were less accurately split than uncoated (P = 0.03 and 0.0019 for each half) and scored (0.0001 for both halves) tablets.ConclusionThese findings have potential clinical implications on treatment outcome and the development of antimicrobial resistance. Investment by drug companies in a wider range of dosage units, particularly for narrow therapeutic index and critical dosage medicines, is strongly recommended.

Highlights

Tablet splitting is widely practised in many areas of healthcare
We investigated the practice of tablet splitting in the low-income setting of Laos
Participants were requested to divide all drugs into halves with the exception of phenobarbitone, where one set was divided into halves and another into thirds, as is commonly required in paediatrics

Summary

Introduction

Tablet splitting is widely practised in many areas of healthcare. In the German primary care setting in 2006, an estimated one quarter of all drugs were split and in a large elderly care home in Canada 35% of all tablets were split (Fischbach et al 2001; Quinzler et al 2006). The primary reason for tablet splitting is to increase dose flexibility, for the elderly, children and those requiring titrating or tapering doses (Fischbach et al 2001; Cohen & Cohen 2002; van Santen et al 2002). Drug costs per unit of active pharmaceutical ingredient (API) frequently decrease with increasing dose or flat charges may exist, independently of dose. Tablet splitting can have an economic incentive, benefitting both the individual patient and the healthcare provider. Estimates of cost saving for splitting statins from innovative pharmaceutical companies are as high as

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Discussion

Conclusion