Tablet Splitting Practice And Its Implications
According to the World Health Organization (WHO), health is defined not only as the absence of disease, but also as a state of physical, psychological and social well-being as an individual, as well as collectively. Thus, the concept of public health acknowledges the fact that health worker interventions include not only clinical services which focus mostly on somatic and psychological aspects, but also social interventions such as production, rent distribution, consumption, housing, work environment, etc. On the other hand irrational use of medicines is also a public health concern and major problem worldwide. Rational use of medications requires that patients receive correct dose at the correct period of time.Tablet Splitting Practice And Its Implications
Public education on this subject is fundamental, since the vast majority of medications are prescribed by a physician, including dosage, frequency, length of treatment and the correct method of administration; and even if a pharmacist were able to solve all the patient’s questions on common administration practices and the best hours to take the medications, it is the patient who decides whether or not to follow those instructions, basing his/her decision on a complex set of family beliefs, social, economic, and health factors. The patient decides whether or not to buy the medication, take the right doses at the correct frequency, and take it as indicated or split it, especially when dealing with over-the-counter medications.
Splitting tablets has become a common and widespread practice in the field of medicine, to ease swallowing of medicines and to address issues in high cost of medication. (Sally 2015) It has been frequently done to correct dosing for patients that need appropriate doses but their implications were seldom discussed and suitable dosages are often not available especially for those that need tapering doses. Various cost-saving activities were used to minimize increasing prescription drug costs including the use of generic medications, selection of more cost-effective medications, and splitting tablets
However, the accuracy of splitting tablets demonstrated to considerably vary. (Rosenberg et. al. 2002) According to the compendia standards, weight and content uniformity must be observed and values should fall within 85-115% of the intended dose with a relative standard deviation of less than or equal to 6% (USP). Large deviations were reported from the ideal weight after splitting the tablets should be considered. If these standards are not correctly followed, incorrect dosing may result from this activity and affect the clinical outcome, especially for medicines with narrow therapeutic indices.Tablet Splitting Practice And Its Implications
Splitting tend to be performed by a variety of people including patients, nurses, pharmacists, caregivers and other health professionals, especially relatives who take care of the patient. Scored tablets might be a very easy task for some because they split it using their hands. However, unscored and coated tablets may require the use of tablet splitters, knife, scissors and even razors.
In a study done by Elliott in 2014, where, five out of eight drugs with narrow therapeutic indices failed to meet the recommended weight deviation at 10%, research showed that there was a significant difference in the accuracy of splitting the tablets between the laypersons and the nurses, deviating by more than 25%. Accuracy may also be affected by the size of the tablet, its shape, hardness, coating, presence of score line, splitting method used and the ability of the person to do it.
Splitting of tablets is done for various reasons; but is associated with certain problems such as inaccurate split resulting in change of dose, enhanced drug degradation due to atmospheric exposure, change in dissolution rate and extent. The accuracy of split is not uniform even with the use of commercial tablet cutters. Often patients with impaired vision, and lack of skilled experience have difficulty during splitting tablets. Accurate dosing may not be possible with splitting of tablets, especially with potent drugs. Tablet splitting may reduce the cost of therapy and may accommodate dose changes as required, but impact on the overall quality of medication used in therapy (Reddy, 2014)
Challenges
The country is facing a big challenge especially in reaching out to those people who are living in low-income settings, or in areas where medications cannot be transported. Antihypertensive drugs are often prescribed for the management of some cardiovascular diseases or conditions, but because of their narrow therapeutic indices, tablet splitting where doses are not accurate, it might pose danger to the patients because of inappropriate doses they receive. The same is true for Antibiotic resistance, it is said that underdosage to antibacterials often lead to multiple drug resistance, since correct dosing is not received by the infected person.Tablet Splitting Practice And Its Implications
If these problems will not be addressed, more people will die. In the 2014 report of the DOH, the 2nd leading cause of morbidity is Hypertension and leading cause of mortality are the diseases of the heart. The use of antibiotics without a prescription has somehow been addressed because of the strict implementation of the FDA, although there are still some drugstores that dispense antibiotics even without prescription. Studies show that some still patronize the use of an antibiotic with higher dose and take only a portion of it, in the hope that there will be the same dose for every part that they take in.
Importance
Nowadays, it is very important for pharmaceutical companies to come up with compliance packages for maintenance drugs and antibiotic regimen, making drug prices more affordable for the public to purchase. Educating the laypersons and other healthcare professionals on the posing risks of inaccurate splitting of tablets is also essential, as it should cover the danger of taking doses that are lower than the prescribed or vice-versa.
The practice of crushing or splitting tablets by patients can lead to health problems, since not all tablets are suitable for this purpose. Splitting prolonged or extended-release tablets may result in increased side effects and a compromise in effectiveness, given the uncontrolled release of the active ingredient, or the latter may be impaired if it is contained in enteric coated tablets or has the potential to irritate the stomach
The government, health agencies and health care professionals should come up with a better health programs for the community. Pharmacists as frontliners of healthcare should educate all the people involved and be the agents of information dissemination and proper transfer of learning to the lay people.
People to involve
It is always said that with proper education comes proper medication leading to proper management of diseases. In one of the researches presented during the Filipino Cardiovascular Disease Summit in 2011, Filipinos had the highest rate of hypertension and hyperlipidemia, and second to Native Hawaiians for diabetes.Tablet Splitting Practice And Its Implications
The Department of Health and Food and Drug Administration should come up with a more effective formula in encouraging patients to comply with the dosage regimen prescribed. Pharmaceutical companies must meet together to formulate dosage forms that are suitable for tablet splitting without making the drug price very heavy for a patient to shoulder and promote cost-effectiveness through proper bioequivalence studies.
The pharmacists and the doctors as health advocates must collaborate with one another in monitoring patient medication compliance. The government on the other hand must come up with a better health program for the Filipinos so that medication compliance may be fully implemented.
Literature Review
There are a variety of reasons why patients split tablets, along with it are problems associated with this process. Inaccuracy in splitting tablets and the resultant dose fluctuations, increased degradation of drug as a result or exposure to air and alterations in the dissolution rate of some formulations are considered as tablet-related factors. Even when commercial tablet cutters are used for accuracy of splitting may be variable. Patient-related factors are dexterity, eyesight or cognition is impaired. (Marriott, 2002)
Compliance is likely to be decreased if the regimen requires tablets to be split. Although splitting tablets may potentially save the patient money, the possible impact on the quality of medication use must be considered. (Marriott, 2002)Tablet Splitting Practice And Its Implications
In the US, some healthcare or managed care company may recommend tablet splitting for reasons such as to adjust the dosing of your medication or to reduce costs. However, it is the responsibility of the healthcare professional to monitor the impact of risks associated with the tablet splitting practice. In addition, the US FDA released guidelines when one considers tablet splitting. Some of the guidelines are as follows: 1) If the tablet is FDA-approved to be split; 2) If a tablet does not include the former in the label, the patient and the healthcare professional should discuss whether to split the tablet or not; 3) If the healthcare asks you to split the tablets, do not split the entire supply of tablets at one time; 4) The healthcare professional will recommend the best method to split the tablet, where the use of tablet cutters may be more appropriate; 5) Most sustained, controlled and time-release medications are not meant for splitting; 6) When switching from one brand to another, the healthcare provider should confirm if the new preferred brand may be split. (fda.gov)
Tablets are sometimes split because the intermediate dose of marketed strengths are not available, and when 2 tablets strength cost the same, as they often do, splitting the higher strength saves money. Although this process may not cause adverse clinical consequences, and can reduce costs for both patients and institutions, but it is not appropriate for all patients neither for all drugs. Using a whole tablet is the safest way to ensure accurate dosing. When it is appropriate, splitting tablets one at a time can minimize under-or overdosing. (The Medical Letter on Drugs and Therapeutics – JAMA Network) Tablet Splitting Practice And Its Implications