Medical
experts have issued a warning about the common practice of tablet splitting,
after a study found that nearly a third of the split fragments deviated from
recommended dosages by 15 per cent or more. Their study, published in the
January issue of the Journal of Advanced Nursing, points out that
the practice could have serious clinical consequences for tablets that have a
narrow margin between therapeutic and toxic doses.And they are calling on
manufacturers to produce greater dose options and liquid alternatives to make
the practice unnecessary.
Researchers
from the Faculty of Pharmaceutical Sciences at Ghent University, Belgium, asked
five volunteers to split eight different-sized tablets using three techniques
commonly used in nursing homes.
They
found that 31 per cent of the tablet fragments deviated from their theoretical
weight by more than 15 per cent and that 14 per cent deviated by more than 25
per cent. Even the most accurate method produced error margins of 21 per cent
and eight per cent respectively.
"Tablet-splitting
is widespread in all healthcare sectors and a primary care study in Germany
found that just under a quarter of all drugs were split" says study lead
Dr Charlotte Verrue.
"It
is done for a number of reasons: to increase dose flexibility, to make tablets
easier to swallow and to save money for both patients and healthcare providers.
However, the split tablets are often unequal sizes and a substantial amount of
the tablet can be lost during splitting."
The
five researchers comprised a pharmacy student, researcher and professor, an
administrative worker and a laboratory technician, ranging from 21 to 55 years
of age. With the exception of the technician, none of the other study
participants had tablet-splitting experience. The authors believe this
replicated nursing home conditions where splitting is not always performed by
professional nurses.
Between
them they split tablets into 3,600 separate quarters or halves using a
splitting device, scissors and a kitchen knife. The eight different tablets
were different shapes and sizes, three were unscored, three had one score line
and the others had two.
The
drugs were prescribed for a range of health conditions, including Parkinson's,
congestive heart failure, thrombosis and arthritis.
After
splitting, each fragment was weighed to see how much they deviated from the
theoretical weight.
Key
results included:
- Using a
splitting device was the most accurate method. It still produced a 15 to
25 per cent error margin in 13 per cent of cases, but this was lower than
the 22 per cent for scissors and the 17 per cent for the knife.
- The
splitting device produced a deviation of more than 25 per cent in eight
per cent of cases, compared with 19 per cent for the scissors and 17 per
cent for the knife.
- Some drugs
were much easier to split accurately than others. The easiest to split
produced an overall error margin (15 per cent deviation or more) of two
percent and the most difficult tablets produced an error margin of 19 per
cent.
"Tablet
splitting is daily practice in nursing homes" says Dr Verrue.
"However, not all formulations are suitable for splitting and, even when
they are, large dose deviations or weight losses can occur. This could have
serious clinical consequences for drugs where there is a small difference
between therapeutic and toxic doses.
"Based
on our results, we recommend use of a splitting device when splitting cannot be
avoided, for example when the prescribed dose is not commercially available or
where there is no alternative formulation, such as a liquid.
"Staff
who are responsible for splitting tablets should receive training to enable
them to split as accurately as possible. They should also be made aware of the
possible clinical consequences of dose deviations.
"We
would also like to see manufacturers introduce a wider range of tablet doses or
liquid formulations so that tablet splitting becomes increasingly unnecessary.
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