Pearls

Pros and cons of pill splitting

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May reduce cost and fine-tune therapy, but is it safe?


 

References

Clinicians and patients look to pill splitting to reduce psychotropics’ costs and fine-tune pharmacotherapy, but pill splitting has not been rigorously studied for safety or efficacy. It is important to understand the risks and benefits of pill splitting before you recommend the practice to patients.

Pros of pill splitting

Lower costs for patients. Many psychotropics come in multiple strengths, and one larger pill often costs less than 2 smaller pills of equivalent dosage.1 Writing a prescription for a higher dose and instructing the patient to cut the pill in half can lower costs.

Fine-tune titration. Pill splitting allows you to prescribe a lower strength to gradually titrate dosages up or taper them down. This practice can prevent side effects and improve adherence because a lower dose may have a more favorable pharmacokinetic profile.

Improve tolerability. Patients might better tolerate half a pill taken twice daily rather than an entire pill once daily. A smaller dose may prevent a spike in serum level, which could aid tolerability.

Questions to ask before you recommend pill splitting
  1. Will there be a cost saving for the patient?
  2. Can the patient understand and follow your recommendations?
  3. Can the patient tolerate minor dosage variability that can occur with pill splitting?
  4. Is the medication’s integrity maintained when the pill is split?

If the answer is yes to all 4 questions, then pill splitting is an option.

Cons of pill splitting

Unequal dosing. In most instances, pill splitting leads to slightly unequal dosing.2 This could be a problem if:

  • the medication such as lithium has a narrow therapeutic index
  • the patient’s condition is unstable
  • the patient’s condition is stable but minor dose variations might cause problems, such as a patient who relapses with small dosing changes.
Slow-release tablets. Pill splitting is contraindicated if the pill is enterically coated or has a slow-release mechanism that will be compromised if the pill is broken (Table).

Table

Appropriate and inappropriate medications for pill splitting

OK to splitDo not split
Adderall tabletsAdderall XR capsules*
Effexor tabletsEffexor-XR capsule*
Paxil or paroxetine tabletsPaxil CR
Prozac 10 mg tablet or fluoxetine tabletsProzac 20 mg capsule
Risperdal tabletRisperdal M-TAB
TegretolTegretol XR
Wellbutrin and bupropion tabletsWellbutrin XL
Zyprexa tabletsZyprexa Zydis
Abilify tabletsConcerta capsules
Celexa or citalopram tabletsCymbalta capsules
Lamictal tabletsDepakote ER
Lexapro tabletsEquetro*
Luvox tabletsEskalith CR, Lithobid tablets
Remeron or mirtazapine tabletsGeodon capsules
Seroquel tabletsRitalin LA*
Zoloft tabletsStrattera capsules
* Capsule can be opened and contents sprinkled on food
Tablets may have uneven shapes, making even cuts difficult
Dosage confusion. With cognitively impaired patients, pill splitting could lead to confusion and possible incorrect dosing.

Scoring. Cutting unscored tablets can be difficult, especially if the pills are not round or oval. Because patients can get injured using a knife, recommend pill cutters, which are available at most pharmacies.

Capsule splitting. Some psychotropics are sold only in capsules. Some capsules can be opened and sprinkled on food, but splitting the contents into approximately equal dosages can be difficult.

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