Health Care Hot Topic: Tablet Splitting New Article!

[DoctorPardi]

We have just published a new article on the SDN Front Page, check it out here: Health Care Hot Topic: Tablet Splitting

Health Care Hot Topic: Tablet Splitting

By Student Doctor Network
Posted on July 25, 2007 e
Filed Under Health Care Policy and the Student Doctor, Pharmacy (PharmD)

Adapted by Sarah M. Lawrence
Used with permission

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:

Hope you enjoy and feel free to discuss it here!

Brandon Pardi
Editor-in-Chief
SDN Front Page

[OUTexan]

I have seen an insurance rejection from WellPoint I believe, that comes up with a rejection saying, "Tablet splitting opportunity exists." You have to call and get the override's for it. One time it was crestor. Copay was $25 with the tablet cutting and $25 without tablet cutting. This just seems like a way for the insurance company to save money. It is hard to talk a patient into cutting a tablet in half if they are still paying the same.

However, I can see a good benefit in splitting tablets for cash customers. How many of you guys fill a script of Viagra 50 mg with Viagra 100 mg and have them split them to save about 30 bucks?

[Farmercyst]

Maybe this is inexperience talking, but if the copay is the same whether they split or not, aren't they saving $25 by splitting since their one month supply becomes 2 months supply if they split. It would mean they don't have to pay another copay when they would normally have to come back for a refill.

[OUTexan]

Yea, but that is a $25 dollar copay for a 30 day supply.

#15 Crestor 20mg taking 1/2 daily = $25
#30 Crestor 10 mg taking 1 daily = $25

Would you split the tablets for the same price each month? It is just a way for insurance companies to make more money.

[All4MyDaughter]

OUTexan - I wouldn't split if it didn't save me money. The real savings comes for cash-paying customers. Or in the case of the VA, having patients split tablets allows the government to save on drug costs, which in turn allows them to serve more veterans, etc.

[npage148]

The only time I ever time I endorse tablet spilitting is when it saves the patient directly. Why hassle cutting tablets if its not gonna put money in your pocket.

Whats the popular censor on splitting tablets that arn't scored but are in theory splitable (ie NOT extended release, eneteric coated)? One patient was paying cash for his Coreg and was on teh verge of quitting to take 1 bid casue of the cost. I set him up with taking 1/2 bid. He was more than happy to deal with splitting the tabs.

[spacecowgirl]

Originally Posted by OUTexan

Yea, but that is a $25 dollar copay for a 30 day supply.

#15 Crestor 20mg taking 1/2 daily = $25
#30 Crestor 10 mg taking 1 daily = $25

Would you split the tablets for the same price each month? It is just a way for insurance companies to make more money.

Not always. Some give you a two-month supply for one copay.

[Shmy2008]

I've always heard that you can't guarantee that one-half the dose is in one-half of an unscored tablet, whereas scored tablets are made to have one-half the dose on either side of the score. In other words, halving an unscored tablet is likely a b-a-d idea.
From my own experience (earlier today, as a matter of fact)... halving an unscored tablet is difficult. I was halving furosemide 20 mg tabs for a LTC packing facility - I rejected about five of my futile attempts at cutting the tabs - I almost always got 2/3, 1/3. I can only imagine how well it would go if I was about 50 years older, a bit less nimble, and a lot more blind...

[acetyl]

Originally Posted by Shmy2008

I've always heard that you can't guarantee that one-half the dose is in one-half of an unscored tablet, whereas scored tablets are made to have one-half the dose on either side of the score. In other words, halving an unscored tablet is likely a b-a-d idea.
From my own experience (earlier today, as a matter of fact)... halving an unscored tablet is difficult. I was halving furosemide 20 mg tabs for a LTC packing facility - I rejected about five of my futile attempts at cutting the tabs - I almost always got 2/3, 1/3. I can only imagine how well it would go if I was about 50 years older, a bit less nimble, and a lot more blind...

Yeah I agree with this. If the tablets are scored, then cool, try to cut costs all around. If not, it's probably not a good idea, especially if it's a really small tablet. Plus, some of the not-so-small tablets can tend to "shatter" if they're not scored and tend to not be a half a tablet.

In the case of the many people who buy Cialis, Levitra, Viagra, whatever and their insurance won't pay anything, I don't see anything wrong with trying to save 'em some money. Plus, most of these people who are buying 100mg of Viagra aren't taking that entire pill over the course of the night-they usually are breaking it into smaller pieces anyway.

On another note...I once sold Norvir with Cialis to a patient. It was kind of awkward to say the least.

[npage148]

Originally Posted by acetyl

On another note...I once sold Norvir with Cialis to a patient. It was kind of awkward to say the least.

Ive done it too!

[PharmDstudent]

Here's a fundamental question: Why is a 100mg Viagra the SAME price per tablet as the 50mg Viagra? People wouldn't have to do tablet splitting if they were charged a price that was proportional to the milligram.
I've wondered about this dynamic for a few years now...

[All4MyDaughter]

Being HIV+ doesn't preclude sexual activity. You just have to practice safe sex and should inform your partner, etc. Even if both partners are HIV+ barrier contraception is recommended b/c the HIV virus has many strains and can mutate.

[acetyl]

Originally Posted by PharmDstudent

Here's a fundamental question: Why is a 100mg Viagra the SAME price per tablet as the 50mg Viagra? People wouldn't have to do tablet splitting if they were charged a price that was proportional to the milligram.
I've wondered about this dynamic for a few years now...

At Wag's, 10mg Cialis is more expensive for #30 than BOTH #30 of the 5mg and 20mg. Guess why? The 10mg sells more...

[DoctorPardi]

I am interested to know what the cost of production for a pill like viagra is. I mean purely the cost to manufacture it. I am interested because I assume the vast majority of the cost of a drug is involved in the development, testing, approval and promotion vs the cost of production per milligram.

So I would bet pfizer is losing or gaining an insignificant amount of money by charging a flat rate for all size pills when compared to the other costs of getting the eventual product to market. However my theory is based on a lot of assumptions that may not be correct.

[Caverject]

It was proven back in 2003 in a JAPhA article that this is a non-issue.

[RPedigo]

Did they prove that each pill had a homogeneous distribution of medication on each side of the tablet? I'd assume the answer is that it is always homogeneous, but how do they know there's not more binding material and less active ingredient on one side of the pill versus the other?

My apologies if this is a dumb question.

[PharmDstudent]

Originally Posted by RPedigo

Did they prove that each pill had a homogeneous distribution of medication on each side of the tablet? I'd assume the answer is that it is always homogeneous, but how do they know there's not more binding material and less active ingredient on one side of the pill versus the other?

My apologies if this is a dumb question.

Sometimes pharmacists mix compounds using geometric dilution. This is how the process of geo. dilution works: You take X amount and mix it with an equal weight of Y. Now you have equal amounts of both substances, but you have doubled the overall weight. If you want to add more ingredients, you have to add an amount equal to your new weight. This could go on forever. After you add new substances, you have to mix the amount very well.
I think the goal behind geo. dilution is to combine substances that have the potential of being equally dispersed. If you add too much of an ingredient, you could end up with portions of your mix that will be more of one thing and less of another.

[sdn1977]

Originally Posted by Caverject

It was proven back in 2003 in a JAPhA article that this is a non-issue.

Pill splitting was also shown to be a significant (38%) & serious source of error as reported by ISMP in May 2006 which was an actual "study" done by the VA & the Association of Consultant Pharmacists of more than 400 patients (the study was criticized for its small n).

Most states are working toward not just discouraging this practice, but making the practice of insurance companies requiring this against the law - altho the VA operates outside of all state laws.

I'm curious what the response was from those who read the Journal of Clinical Psychology.......did they publish it?

[All4MyDaughter]

Yes, that particular Letter to the Editor was published in the Journal of Clinical Psychology.

[sdn1977]

Originally Posted by All4MyDaughter

Yes, that particular Letter to the Editor was published in the Journal of Clinical Psychology.

I couldn't find that letter, but could it be in reference to the original work from 2003?:

This is the html version of the file http://www.amcp.org/data/jmcp/Research-401-407.pdf.

The more recent information is from ISPM:

http://www.ismp.org/newsletters/acut...s/20060518.asp

from 2006 which gives the more current standards of practice with more specific and complete recommendations.

I think the VA also changed their recommendations in 2006 as well, but its hard to locate their "topics in safety".

38% error rate is pretty high, although given a previous discussion of "harm" and "error"....perhaps looking at the 9% harm rate doesn't look too bad (altho it does to me!). 2% required hospitalization, which in hospital admission statistics is very high when it can be related to one particular event - especially a drug adverse event. Our standard of practice only allows deviation by 0.5% - so it seems anyway you look at it, it is not a practice to be encouraged unless absolutely required....and fortunately, it is being now actively discouraged in many settings - even the VA.

On a side note, if you look into the psychiatry journals (not psychology) and pill-splitting, there are interesting articles which look not at the pharmacy/pharmaceutical end of things, rather at the practice of pill-splitting which is a reflection of a psychiatric illness (this is when patients do this voluntarily - not on the advice of a provider) and using this as one of the diagnostic indicators. I've not kept up on the DSM criteria, but I know years ago it was discussed. Perhaps there is a psychiatry pharmacist who could comment?

Its interesting that some of the work from 2003 actually used an SSRI. Coincidental only, I think.

[All4MyDaughter]

Tablet splitting is not discouraged by the VA. It's widely used in situations where it is appropriate (medication suitable for splitting, patient able to comply, etc). I can't say I disagree with the practice if employed properly.

[Doctor M]

Originally Posted by All4MyDaughter

Tablet splitting is not discouraged by the VA. It's widely used in situations where it is appropriate (medication suitable for splitting, patient able to comply, etc). I can't say I disagree with the practice if employed properly.

The only time I agree with tablet splitting is when the tablets are scored and I know the patient can handle the "splitting". Ive tried splitting some of these drugs and was unsuccessful. One lady asked me to split her Norvasc 2.5.

[All4MyDaughter]

Doctor M - yeah, it needs to be handled appropriately.

[Doctor M]

Originally Posted by All4MyDaughter

Doctor M - yeah, it needs to be handled appropriately.

Even splitting crestor with a pill splitter is not exact. Ive tried and its not exactly down the middle. I guess I just dont like the idea of splitting tablets. But if it saves money for the ins comp why not...

[ZpackSux]

I blame tablet splitting on the pharmaceutical companies.

Here is a common pricing structure for brand drugs.

10mg = $1.55
20mg = $1.63
40mg = $1.85

Clearly, this tempts cost saving minded pharmacists to split larger tablets. However, pharm companies benefit 2 different ways. First, they make more money on lower strength tabs since it's not priced proportionately.

And they stand to gain a whole lot more when hospital or patients have to double up. And they recommend their tablets not cut.

If tablets are priced accordingly, we would not be having this topic today.

Ortho McNeil has been in full force in promoting 750mg Levaquin.

Here is a typical cost contract.

250mg Tab = $7
500mg Tab = $8
750mg Tab = $16.

250mg IV = $8
500mg IV = $15
750mg IV = $12. So when patient goes from IV to PO...they make more money.

WFT. Why wouldn't I want to cut 500mg tabs into 2?
At the same time, I've seen many hospitals who do not carry 750mg tabs..so they end up dispensing 3 x 250mg tabs.. that's $21 buck per dose. To process a 750mg po daily with 500mg and $250mg would be 2 separate entries which makes most pharmacists to just process it as 3 x 250mg.

[sdn1977]

Originally Posted by ZpackSux

I blame tablet splitting on the pharmaceutical companies.

Here is a common pricing structure for brand drugs.

10mg = $1.55
20mg = $1.63
40mg = $1.85

Clearly, this tempts cost saving minded pharmacists to split larger tablets. However, pharm companies benefit 2 different ways. First, they make more money on lower strength tabs since it's not priced proportionately.

And they stand to gain a whole lot more when hospital or patients have to double up. And they recommend their tablets not cut.

If tablets are priced accordingly, we would not be having this topic today.

Ortho McNeil has been in full force in promoting 750mg Levaquin.

Here is a typical cost contract.

250mg Tab = $7
500mg Tab = $8
750mg Tab = $16.

250mg IV = $8
500mg IV = $15
750mg IV = $12. So when patient goes from IV to PO...they make more money.

WFT. Why wouldn't I want to cut 500mg tabs into 2?
At the same time, I've seen many hospitals who do not carry 750mg tabs..so they end up dispensing 3 x 250mg tabs.. that's $21 buck per dose. To process a 750mg po daily with 500mg and $250mg would be 2 separate entries which makes most pharmacists to just process it as 3 x 250mg.

my point exactly!!! Drug errors & cost/price differences - who is ultimately paying? Truely - your "cost", particularly retail, which most retail pharmacists don't actuallly see after rebates is negliglible. If you don't communicate with your buyer or retail corporate negotiator - you risk getting the pt into big trouble. And for what???? A few pennies on the dollar for you? Why not for the insurance co? - because it is difficult to do & difficult to have the pt understand. Give the pt. a break & "fix" the co-pay - we all have the ability to override it for a reason - this is a justifiable reason - to keep them out of the hospital because the insurance company will not pay for 30mg lisinopril!!!!

Gotta look at the big picture! Some get lost in the picture being the corporate profit, which actually doesn't change, but sometimes the patient gets lost in that mix.

Which brings up the topic....why Levaquin??....but - thats a whole different thread!

[ZpackSux]

ehh...I don't know what my point was...