The Skeptical Cardiologist Begins Pill Splitting: Best Practice or Patient Folly?

Recently the skeptical cardiologist certified his entry into the geriatric fraternity by acquiring a pill splitter.

Why Split Pills?

I’ve been prescribing half doses of various medications to my patients for decades. Sometimes it’s because I need to lower the dosage of, let’s say, a blood pressure medication just a little bit or I  need to up the dosage of a heart failure medication but want to be more cautious than doubling the dosage would allow.
The second reason I have my patients splitting pills is to save money. With generics (which I try to use whenever possible) like amlodipine which often only costs $5 per month this is usually not the issue but for brand name drugs it is huge.
Take rosuvastatin, for example, the widely prescribed, most powerful statin drug which is only available as an expensive brand name drug, Crestor.
My Epocrates iphone app says thirty 10 mg Crestor tablets cost $200 whereas thirty 20 mg tablets costs $189. This is the cost to a patient with no health insurance. Most of my patients have insurance and will be paying a higher tier co-pay for Crestor, perhaps 50$ versus $25. If I prescribe 20 mg tablets to my patient who needs 10 mg tablets and have the patient split them in two, the Crestor will last twice as long and the patient’s cost is halved.

My Pill Splitter and Amlodipine

I had always been vaguely aware of the mechanical issues surrounding pill splitting based on reports from my patients. Concerns about uneven splits or crumbling of the tablets were often expressed.
But I had never personally put a pill in a pill splitter and experienced the act of dividing for myself.

The pill in question was 10 mg of amlodipine, a generic calcium channel blocker used widely for control of blood pressure. In 2014, amlodipine was the #5 most prescribed generic drug in the US with 76 million prescriptions written.
Amlodipine has a long half-life and is usually prescribed as  once daily but it’s peak effects occur 6-12 hours after taking it. For this reason, if patients are noting very high blood pressures right before they take their morning amlodipine combined with very low pressures in the afternoon I will have them divide their pills and take them twice daily. This often eliminates mid afternoon sluggishness and lowers the early morning blood pressure to acceptable levels.
I decided I wanted to take 1/2 of my prescribed a amlodipine twice daily to smooth out its effects. At first I tried to break it in half with my fingers. I failed. I just couldn’t get them to break. (I was able to do this with another blood pressure pill, a long, large, oblong shaped tablet).
Thus began my quest for a pill splitter.
After doing a bit of due diligence I purchased the Apex Deluxe Pill Splitter for $5.89 ( unsponsored link here) from Amazon and it was delivered for free, arriving the next day.
I found that people are remarkably passionate and analytical about their pill splitters. There are 677 reviews on the Apex pill splitter on Amazon and they are often detailed. If you’d like to spend your day learning the nuances of these devices, there is probably no better place than Amazon.

The bottom line for me was that my circular 10 mg amlodipine tablets were split very nicely by the device.
There is definitely some crumbling and loss of a few micrograms of material and when you put the split pill in your mouth you can taste the bitter split pill powder much more quickly than a whole pill.

Issues With Pill Splitting

Superficial  reviews of this topic often say that the American Medical Association formally opposes the practice of pill splitting but the most recent document I found is from the AMA’s Medical Letter which concludes “tablet splitting may not have adverse consequences and can reduce costs for both patients and institutions”

Studies have demonstrated that the practice is safe for a variety of tablets.

Consumer Reports has a document (here) that was created in 2006 and which is widely referenced which lists medications that are considered safe to split but I have not found any documentation to support this.

The FDA studied pill splitting and issued this guidance in 2013.

• If a tablet is FDA-approved to be split, this information will be printed in the “HOW SUPPLIED” section of the professional label insert and in the patient package insert. Also, the tablet will be scored with a mark indicating where to split it.
• If a tablet does not include such information in the label, FDA has not evaluated it to ensure that the two halves of a split tablet are the same in weight or drug content or work the same way in the body as the whole tablet. You should discuss with your healthcare professional whether to split this type of tablet.
• If your healthcare professional asks you to split your tablets, do not split the entire supply of tablets at one time and then store them for later use. That is, make sure that both halves are taken before splitting the next tablet. This is important because split tablets may be affected by factors such as heat, humidity and/or moisture content. For example, a split tablet stored in a damp environment such as in a bathroom medicine cabinet could be affected.
• Your healthcare professional may be able to recommend the best method by which to split a tablet. In many cases, a tablet splitter may be appropriate. However, some tablets may not be suitable for this method because of their unique shape and size—even if they appear to be scored. It is important to discuss this issue with your healthcare professional to determine what is best for you.
• Most sustained, controlled, or timed release medications are not meant for splitting. In those rare instances where splitting is recommended for this type of medication, such information will be printed in the “HOW SUPPLIED” section of the professional label insert and in the patient package insert and will be scored.
• When you switch from one brand of medicine to another, you and your healthcare professional should confirm whether the newly prescribed tablet is splitable, even if the original tablet could be split. The same medications can be manufactured differently, thus may not have been developed to be split.

Personally, on my recent trip to Europe, I violated the third FDA recommendation as I “pre-split” my amlodipine tablets because I didn’t want to take the pill splitter with me.

My Advice To Patients on Pill Splitting

The vast majority of the time it is fine to split tablets for saving money or making medication adjustments.
Use a pill splitter. They are cheap and effective and the act of vigorously slicing your pills with the guillotine-like blade provides a sensory thrill that will get your mornings started on the right note.
Don’t do this with timed-release tablets or capsules (although I have one resourceful patient who opens her capsules and splits the powder within and it seems to work well for her).
Common sense can be our guide as to whether the process of splitting is resulting in fairly equal portions and an acceptable level of crumbling. Ideally, however, even if the resulting fragments seem relatively equal, it is best not to split into quarters (although I have a few patients who have divided their tablets into eighths with no adverse consequences!).
Splitting pills but not hairs and crumblingly yours,
-ACP