Tablet Splitting: Saving Money or Causing Problems?

Tablet splitting can save money, especially for brand-name medicines that aren’t available as generics. Sometimes different strengths of the same medicine cost about the same. To save money, a doctor may write a prescription for a higher strength of a tablet with instructions to use ½ of a tablet per dose. Some insurance companies even recommend this practice to save both the patient and the insurance plan money.

Saving money is good. Unfortunately, splitting some medications may end up causing more harm than good. The chart below outlines some common negative effects that are associated with splitting those medications.

Negative Effect(s)	Medication(s)
More medicine released or too much medicine too fast	Covera-HS (verapamil), extended-release oxycodone and morphine tablets
Reduced stability due to air exposure	K-Lyte Effervescent tablets (potassium chloride)
Upset stomach and/or foul taste in one’s mouth	Cipro (ciprofloxacin), Bayer Low Adult Strength (coated aspirin)
Tablet breaks apart and is unusable	Nitrostat (nitroglycerin)
Uneven dosage, with more medicine in one half than in the other—especially critical when the therapeutic or beneficial dose is nearly the same as the unsafe or toxic dose	Lanoxin (digoxin), Synthroid levothyroxin)

There are other risks involved in splitting medications, which can be particularly hazardous in the elderly. Some patients may not have the needed skill, dexterity, visual ability, or strength to split tablets evenly. Others may not have the mental clarity to select medicines that are safe to split. In these cases, a qualified family member or a caregiver should split the tablets.

The Institute for Safe Medication Practices emphasizes that both patient factors and medication factors must be considered to ensure safety when splitting tablets. ¹

The American Pharmacists Association (APhA) and the American Medical Association (AMA) are formally against the tablet-splitting that some insurance companies have tried to require.² However, the American Pharmacists Association recognizes the widespread practice of tablet-splitting and has established guidelines to help determine if tablet-splitting is safe based on individual patient and product characteristics.

The APhA suggests that uncoated, scored tablets (i.e., tablets with an indented line in the center) are the easiest to split. Tablets that are round, coated, small, or are not scored may be difficult to split accurately. The patient or caregiver must also be physically able and have the mental clarity to divide the tablet as directed. In those circumstances, then consider the following guide from the APhA2.

1. Is the tablet taken for one’s heart such as digoxin (Lanoxin) or for a thyroid condition such as levothyroxin (Synthroid, Euthroid, others)?

  Yes, don’t split the tablet

  No, go to the next question

2. Is the tablet scored (indented line in the center of the tablet)?

  No, don’t split the tablet

  Yes, go to the next question

3. Is the tablet a controlled- or modified-release product (i.e., does it have “ER,” “SA,” “CR,” or “LA” in the name)?

  Yes, go to the next question

  a. Is the tablet scored (indented line in the center of the tablet)?

  No, don’t split the tablet

  Yes, go to the next question

  No, go to the next question

4. Does the tablet contain more than one active ingredient?

  Yes, don’t split the tablet

  No, go to the next question

5. Does the tablet easily break into pieces with minimal handling?

  Yes, don’t split the tablet

  No, go to the next question

6. Is the tablet coated? Does it specify under-the-tongue administration (sublingual) or inserting inside the mouth by the cheek (buccal)?

  Yes, don’t split the tablet

  No, splitting is possible

7. Does it have a foul taste, can it cause birth defects in a pregnant woman if handled, or can it cause mouth irritation?

  Yes, don’t split the tablet

  No, splitting is possible

Remember, even though these guidelines are in place, the best course of action is to discuss your medications with your pharmacist and find out what is safe before splitting tablets. Ask your pharmacist for a tablet-splitting device to help ensure accurate splitting.

Stay active in both mind and body...take care!

Dr. Joe Woelfel

Posted in Geriatric Pharmacology, How to Care for Someone at Home, Medication Management

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