Splitting pills not ideal in elderly cardiac patients

A study in Hong Kong finds high variability of drug content after pill splitting and reports a preference for pills with exact dosages that do not require splitting among elderly cardiac patients. Patient education on proper use of pill cutters is suggested.

“Our results indicate that patients should be supplied with pills with exact dosages whenever feasible. Currently, there is inadequate patient education about pill splitting in Hong Kong. Pharmacists should educate patients on the technique in using and cleaning pill cutters if pill splitting is inevitable,” suggested the authors. [Hong Kong Med J 2021;doi:10.12809/hkmj208455]

In the study, 193 patients (mean age, 73.09 years; male, 59.6 percent) on lisinopril, amlodipine, simvastatin, metformin, or perindopril requiring pill splitting were recruited from the Prince of Wales Hospital (cardiac clinic, 79.8 percent; hypertension clinic, 20.2 percent). Enrolled patients were randomized into either group A (n=106; pill splitting with patients’ own technique) or group B (n=87; pill splitting with technique taught by pharmacist or pharmacy student) following initial clinic visit. Patients’ existing medication regimens and dosages were unchanged throughout the study.

At mean follow-up of 23.1 weeks, two halved tablets split by the patients were randomly selected as samples to be weighted with assays performed. The patients also underwent blood tests, blood pressure (BP) measurements, and assessment of knowledge about and attitude towards pill splitting

Results showed no statistically significant increase in the proportion of patients in group A (from 39.13 percent to 47.82 percent; p=0.523) and group B (from 48.94 percent to 51.06 percent; p=1.000) whose halved tablets met the assay specification at follow-up visit compared with baseline.

Patients in group B who received education on pill splitting technique had a significant reduction in mean triglyceride level (from 1.62 mmol/L to 1.36 mmol/L; p=0.049) and increase in mean heart rate (from 73.97 bpm to 77.92 bpm; p=0.026), as well as numerical improvements in mean diastolic BP, high-density lipoprotein, low-density lipoprotein and total cholesterol.

Although 72.28 percent of patients reported cutting pills for at least 1 day’s quantity each time, pill cutters were used by only 24.75 percent of patients, whilst 57.43 percent of patients split pills with their bare hands. The main reasons for not using pill cutters included: current method was felt to be effective in splitting pills evenly (68.1 percent), using pill cutters was time consuming (34.09 percent), and pills could not be split evenly with pill cutters (15.91 percent).

A similar proportion of patients found pill splitting troublesome at baseline (29.70 percent) and at follow-up (24.75 percent) (p=0.063). Major difficulties encountered by patients included difficulty in splitting pills evenly (17.00 percent), split pills became fragmented (10.00 percent), and difficulty in seeing small-sized pills clearly (9.00 percent).

As such, 98.21 percent of patients preferred taking tablets with exact dosages without the need for pill splitting.

Patient education led to significant improvements in understanding of pill splitting in group B, specifically on ‘using pill cutters for pills to be divided into more accurate doses’ (p=0.002), ‘pills should be put inside the pill cutter’s triangular tip’ (p=0.008), ‘pill cutters should be stored in a cool, dry place and away from sun or moisture’ (p=0.003).