08 Apr 2020 Best Evidence Webinar: Pill splitting: making the most of medications in a time of need – can we make it practical for patients?
A brief presentation by Dr. Tom Perry with commentary from Dr. Camille Gagnon and Dr. Brenda Schuster and maximum time for audience participation with questions and brief contributions from participants, including lay people taking medications.
Learning objectives (for professionals): by the end of this session, participants should be able to:
- Discuss the concept of pill splitting as a way to dose appropriately.
- Describe how pill-splitting can cut the costs of medications for patients, stretch prescriptions, and reduce trips to the pharmacy.
- Identify when and how to split pills, tips and tricks of the trade.
- Determine when not to split pills, and whether some extended release tablets can be split.
- List some common oral medications that can be split safely and easily.
This event has already taken place. Scroll down to view the video recording.
PRESENTERS:
- Tom Perry MD, FRCPC – General Internist/Clinical Pharmacologist, Chair of the Education Working Group, Therapeutics Initiative, University of British Columbia, Vancouver, BC.
- Brenda Schuster PharmD – Academic Family Practice Unit, U. Saskatchewan College of Medicine, Regina, SK.
Special thanks to Camille Gagnon PharmD – Assistant Director, Canadian Deprescribing Network, Montreal, QC.
DATE: Wednesday, April 8, 2020
TIME: 16:00 – 17:00 (4:00 – 5:00pm) Pacific Daylight Time (UTC/GMT -8hrs)
COST: FREE
CME CREDITS: MainPro+/MOC Section 1 credits: 1.0. You must register, attend the webinar and complete the evaluation in order to receive your certificate.
Click here to view/download the handout (slides in PDF format).
Click here to view a short (5-minute) video on this topic.
Click here to view the Therapeutics Letter Special Edition March 2020 on this topic, available in English, French, Spanish, Portuguese and Chinese.
Steve Larigakis
Posted at 23:37h, 13 AprilHow do I write a prescription so that my patient has a chance to receive a larger number of doses, if the patient is willing to split tablets? If my prescription is intended as a longer duration, I don’t want the dispensing pharmacist to adjust it by reducing the number of pills to split.
Steve Larigakis MD, Surrey, BC
[No conflict of interest]
Tom Perry
Posted at 23:39h, 13 AprilHere is how I might write a prescription for atorvastatin 40mg/d, intended to last for 3 months or 100 days, which is typically the longest dispensing for which PharmaCare will reimburse. I also try to practice “indication-based prescribing”, showing the purpose as part of the label.
Patient name, Date
We will consider posting other responses, especially from dispensing pharmacists or prescribers who have sorted out how to write pill-splitting prescriptions using an EMR.
Dr. Thomas L Perry jr MD, FRCPC
Chair, Education Working Group
Editor in Chief, Therapeutics Letter
UBC Therapeutics Initiative
Gloria Chu
Posted at 10:22h, 14 AprilAdding the words “Patient will split at home, take 1/2 tablet = 40mg daily. To last 90 days” is really helpful to clearly indicate to a dispensing pharmacy that higher strength tablets are requested and will be split by the patient. This can save time and confusion in case of a language barrier or if someone else drops off the Rx who is not aware of the conversation between patient and prescriber.
If an Rx is faxed in as “atorvastatin 80mg 0.5 tab po od for 3 months” but the patient’s profile shows previous dispensing has always been for atorvastatin 40mg once daily, the pharmacy may default automatically to exactly what was dispensed previously. The dispensing pharmacist may assume patient preference not to split. Therefore, specifying the need “to split tablets” would be a great way to prevent lapses in communication.
As for the 30-day supply, there is a Canadian Pharmacists Association recommendation for such a limit during the Covid-19 pandemic to mitigate impact of actual or potential drug shortages (https://www.pharmacists.ca/news-events/news/covid-19-and-the-responsible-allocation-of-medications-to-patients/). Most pharmacies have adopted this practice, but it is only a recommendation, not a rule. The recommendation and states “unless clinically justified” so pharmacies and pharmacists can make decisions to dispense longer – up to 100 days’ supply in BC as per PharmaCare reimbursement policy.
If a patient lives far away, is high risk and should stay home as much as possible, or has low income so more frequent dispensing fees could cause significantly more burden, the pharmacist has discretion to accommodate.
Note that some drugs were already shorted before the pandemic (which can depend on the individual pharmacy’s prescription volume and wholesale suppliers as shortages do vary).
So to summarize:
(1) Include as much detail on Rx as possible, including the instruction “split tablets to = x mg” to indicate the need to split, and the desired tablet strength and quantity to be dispensed;
(2) Although a > 30-day supply cannot be guaranteed now, many pharmacies and pharmacists will still make the decision to dispense longer for patients who require this, depending on their inventory and supplier status.
Gloria Chu, dispensing pharmacist, BC
[No conflict of interest]
Kathy Walsh
Posted at 04:54h, 27 MayHi, I’m a community pharmacist who remembers when all prescriptions were hand-written and some barely legible so I’m glad we’ve moved on to the printed ones. While I’ve come to appreciate the computer-generated prescriptions, many times they are confusing, having conflicting information. Most times, we pharmacists can unravel the confusion without need to call the prescriber. An example would be for insulin, where the prescriber orders 2700 vials of insulin when clearly the computer calculated total number of UNITS. However, sometimes we are not clear what is meant and when we check with the patient, they are also confused so we have to fax or call you to clarify. Often this is because there are old notes that should have been deleted or as many as three different SIG codes embedded in the prescription in various ways. When this happens, you will often hear one of our staff exclaim “ Do they ever proof-read what they have written BEFORE they send it?” Especially when the SIG says to take a suppository PO haha!
I think that in order to ensure that the patient gets the higher strength 80 mg atorvastatin, somehow the fact that the intention “ Patient is to split 80 mg tabs and take one-half tab per day” needs to be clearly written. Your example does this nicely and should lead to the dispensing of the medication as you intended! I commend you for including the indication ( for this is really helpful!) however, the word “ label” might be interpreted that the words “ for secondary prevention of IHD” should be included on the pill bottle label, which isn’t necessarily a bad thing, provided the patient understands what it means or wouldn’t be embarrassed by the indication , such as “ For erectile dysfunction “ or “ vaginal yeast infection”.
When the prescriptions are faxed directly from the computer to the pharmacy, I realize there are many challenges in making sure the prescription information is both accurately recorded in the patients chart as well as clearly understandable to the staff at the pharmacy. (It is most often a pharmacy technician that first enters the prescription) …. in cases where you first print the Rx and either give it to the patient or manually fax it, you can hand-write things on that paper that help clarify the order or you can scratch out old notes that no longer apply. And as always, remember if you need to, you can always call us.
One other thing if I may, with COVID19 most new prescriptions are arriving at the pharmacy via fax, sometimes hundreds or these per shift depending on the pharmacy. It would be really helpful if you could note on the prescription whether the patient needs the medication filled right away or will call us when they need to order it. Advise the patient to call the pharmacy before they show up as often patients come before we have a chance to fill their order and they don’t like waiting around or making a second trip back later. These are little things that really go a long way when it comes to positive prescriber-pharmacy relationships!
Thanks for your time!
Sincerely, a NS pharmacist 🙂
Alan Cassels @ TI
Posted at 16:06h, 07 AugustKathy thank you for these thoughtful suggestions. Anything that improves the clarity and precision of prescribing is helpful indeed.