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Concerns regarding tablet splitting: a systematic review. BJGP Open 2022; 6:BJGPO.2022.0001. [PMID: 35193886 DOI: 10.3399/bjgpo.2022.0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 01/07/2022] [Accepted: 01/31/2022] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Tablet splitting can provide dose flexibility and cost savings; however, pharmaceutical representatives typically discourage the practice. AIM To identify and summarise all published concerns related to tablet splitting and to present the experimental evidence that investigates those concerns. DESIGN & SETTING Systematic review and qualitative synthesis of tablet-splitting concerns and evidence. METHOD Medline and EMBASE databases were searched over all years of publication for articles in English discussing the splitting of tablets. Eligible articles included original research, narrative reviews, systematic reviews, and expert opinion. RESULTS After removing duplicates, 1837 potentially relevant articles underwent dual review, whereupon 1612 articles were excluded based on title and abstract. After examination of 225 full texts, 138 articles were included (one systematic review, four narrative reviews, 101 original research articles, and 32 opinion articles). The described concerns included difficulty breaking tablets, loss of mass, weight variability, chemical instability, overly rapid dosing if sustained-release medications are split, non-compliance, and patient confusion resulting in medication errors. No substantive evidence was found to support concerns regarding loss of mass, weight variability, chemical instability, or non-compliance. Evidence does support some older adults struggling to split tablets without tablet splitters, and the inappropriateness of splitting sustained-release preparations, given the potential for alteration of the rate of drug release for some products. CONCLUSION With the exception of sustained-release tablets, which should not be split, and excepting those older people who may struggle to split tablets based on physical limitations, there is little evidence to support tablet-splitting concerns.
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Kaewsaengeak C, Pienputtarapong U, Tocharoenchok T. The effectiveness of split tablet dosing versus alternate-day dosing of warfarin: a randomized control trial. Sci Rep 2021; 11:24060. [PMID: 34912021 PMCID: PMC8674310 DOI: 10.1038/s41598-021-03606-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 12/07/2021] [Indexed: 11/23/2022] Open
Abstract
Due to large dosage variation, a variety of warfarin prescription regimens are utilized for specific doses such as tablet splitting, or pill strength alternating. The clinical comparison between the two is lacking. We hypothesize that both approaches result in different times in therapeutic range. We randomized patients with specific warfarin dosage and stable INR for 6 months or longer to receive the whole tablet, alternate-day dosing or the split tablet, same daily-dosing regimen without initial dose change and followed them every 6 weeks for 6 months. The primary outcome was a time in therapeutic range of 2.0–3.0. The secondary outcomes included dosage, compliance, INR, anticoagulant-related events. A total of 66 patients were enrolled, 32 randomly assigned to the split tablet regimen (group S) and 34 to the alternate-day regimen (group A) with two withdrawers. The mean age was 58.6 ± 8.5 years. All baseline characteristics of both groups were similar. The average time in therapeutic range was 72.8 ± 25.4% in group S and 74.9 ± 22.0% in group A (p = 0.72). There were no significant differences in warfarin dosage, compliance, INR and, complications between the two groups. Both warfarin prescription methods, the split tablet and the alternate-day had comparable time in the therapeutic range.
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Affiliation(s)
| | - Usanee Pienputtarapong
- Ambulatory Care Unit, Pharmacy Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand
| | - Teerapong Tocharoenchok
- Division of Cardiothoracic Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand.
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Wattanaruengchai P, Nathisuwan S, Rattanavipanon W, Chulavatnatol S, Kongwatcharapong J, Mitsuntisuk P, Chaiyasothi T, Kritsanapipat D, Phrommintikul A, Chaiyakunapruk N, Likittanasombat K, Lip GYH. Prescriber compliance to direct oral anticoagulant labels and impact on outcomes in Thailand. Br J Clin Pharmacol 2020; 87:1390-1400. [PMID: 32857417 DOI: 10.1111/bcp.14535] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/06/2020] [Accepted: 08/21/2020] [Indexed: 11/29/2022] Open
Abstract
AIMS This study aimed to evaluate the prescriber compliance to the approved labels of direct oral anticoagulants (DOACs) and impact of appropriateness of dosing on clinical outcomes. METHODS A retrospective study was conducted using simple-stratified random sampling of adult patients receiving ≥6 months of DOACs for various indications during 2013-2017 in 10 tertiary care hospitals. Patients were classified into 3 dosing groups including approved dose, underdosing and overdosing based on the Thai Food and Drug Administration-approved labels. Cox proportional hazard models were used to evaluate the impact of different dosings on thromboembolic and bleeding events. RESULTS From 1200 patients included in the data analysis, prescribing of DOACs was consistent with the approved indications in 1130 cases (94.2%) while 70 patients (5.8%) received DOACs despite having contraindications or with off-label usage. Among 1026 cases of dosing evaluation cohort, 688 patients (67.1%) received approved doses. There were 227 (21.9%) and 110 (10.7%) cases of underdosing and overdosing, respectively. Multivariate analysis showed that underdosing was associated with an increased risk of thromboembolism 3.023 (95% confidence interval [CI]: 1.291-7.080; P = .011) while overdosing was associated with an increased risk of bleeding requiring hospitalization (adjusted hazard ratio, 3.045; 95% CI, 1.501-6.178; P = .002) and Bleeding Academic Research Consortium type 2 or more (adjusted hazard ratio, 2.196; 95% CI, 1.083-4.452; P = .029). CONCLUSION Prescribers' compliance to approved indications were high. However, 1/3 of DOAC prescriptions were inconsistent with approved dosing. Dosing deviation was associated with an increase in adverse clinical outcomes.
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Affiliation(s)
| | - Surakit Nathisuwan
- Clinical Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Wipharak Rattanavipanon
- Clinical Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Suvatna Chulavatnatol
- Clinical Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | | | | | - Thanaputt Chaiyasothi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Srinakharinwirot University, Nakhon Nayok, Thailand
| | | | - Arintaya Phrommintikul
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Nathorn Chaiyakunapruk
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, Utah, USA
| | - Khanchit Likittanasombat
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine at Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, UK
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Gharaibeh SF, Tahaineh L. Effect of different splitting techniques on the characteristics of divided tablets of five commonly split drug products in Jordan. Pharm Pract (Granada) 2020; 18:1776. [PMID: 32377280 PMCID: PMC7194171 DOI: 10.18549/pharmpract.2020.2.1776] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 04/13/2020] [Indexed: 01/06/2023] Open
Abstract
Objective To determine the accuracy, variability, and weight uniformity of tablet subdivision techniques utilized to divide the tablets of five drug products that are commonly prescribed for use as half tablets in Jordan. Methods Ten random tablets of five commonly subdivided drug products were weighed and subdivided using three subdivision techniques: hand breaking, kitchen knife, and tablet cutter. The five commonly subdivided drug products (warfarin 5 mg, levothyroxine 50 μg, levothyroxine 100 μg, candesartan 16 mg, and carvedilol 25 mg) were weighed. The weights were analyzed for acceptance, accuracy, and variability. Weight variation acceptance criteria were adopted in this work as a tool to indicate the properness of the subdivision techniques used to produce acceptable half tablets. Other relevant physical characteristics of the five products such as tablet shape, dimensions, face curvature, score depth, and crushing strength were measured. Results All tablets were round in shape, had weights that ranged between 100.63 mg (standard deviation=0.99) and 379.04 mg (standard deviation=3.00), and had crushing strengths that ranged between 23.29 N (standard deviation=3.58)and 103.35 N (standard deviation=14.98). Both candesartan and carvedilol were bi-convex in shape with an extent of face curvature equal to about 33%. In addition, percentage score depth of the tablets had a range between 0% and 24%. The accuracy and variability of subdivision varied according to the subdivision technique used and tablet characteristics. Accuracy range was between 81% and 109.8%. Moreover, the relative standard deviation was between 1.5% and 17.4%. Warfarin 5 mg subdivided tablets failed the weight variation test regardless of the subdivision technique used. Subdivision by hand produced half tablets that were acceptable for levothyroxine 50 μg and levothyroxine 100 μg. Subdivision by knife produced half tablets that were acceptable only for candesartan tablets. However, the tablet cutter produced half tablets that passed the weight variation test for four out of the five drug products tested in this study. Conclusions The tablet cutter performed better than the other subdivision techniques used. It produced half tablets that passed the weight uniformity test for four drug products out of the five.
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Affiliation(s)
- Shadi F Gharaibeh
- PhD. Associate Professor. Faculty of Pharmacy, Jerash University. Jerash (Jordan).
| | - Linda Tahaineh
- PharmD, MS. Professor. Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science & Technology. Irbid (Jordan).
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Son KB. Recent trends in tablet subdivision and factors affecting subdivision in South Korea: A cross-sectional study. Medicine (Baltimore) 2020; 99:e19990. [PMID: 32358374 PMCID: PMC7440328 DOI: 10.1097/md.0000000000019990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Tablet subdivision by physicians or patients frequently occurs in various clinical settings for multiple reasons, including dose adjustment, alleviation of swallowing difficulties, or cost savings. However, not all tablets are suitable for subdivision, and it might cause side effects. It is informative to know which medicines are regularly subdivided, which healthcare institutions prescribe subdivided medicines, and to whom the medicines are prescribed from the perspectives of quality of care and patient safety. In this study, we aimed to examine recent trends in tablet subdivision and to address factors associated with subdivision of tablets both at the patient and healthcare institution levels.The yearly claims data in 2016 retrieved from the National Patients Sample provided by the Health Insurance Review and Assessment (HIRA-NPS). This study used descriptive statistics to examine characteristics of medicines that were frequently prescribed in subdivided forms, and retrieved information regarding the medicines to assess the appropriateness for tablet splitting. Then, we selected five medicines, and performed a multivariate logistic regression analysis to estimate the effect of the variables of interest on tablet subdivision.We presented the top 25 medicines prescribed in subdivided forms in 2016, and confirmed these medicines could be relevantly halved according to their Summary of Product Characteristics. Of the 25 medicines, 14 (56%), 5 (20%), and 3 (12%) medicines belonged to the respiratory system (R), nervous system (N), and systemic hormonal preparations (H), according to the first category of Anatomical Therapeutic Chemical (ATC) classification system, respectively. Being female at the patient level and tertiary healthcare institutions and private owned institutions at the institution level were positively associated with subdivision of medicines.Subdivision of tablets frequently occurred for vulnerable populations with various reasons. Female and geriatric patients are prescribed split medicines for clinical reasons, while low-income patients are prescribed nonsplit medicines for cost savings. It would be better if medicines were not so small, and if they had dividing lines on their surfaces to enable successful splitting of the tablet and to protect the health of vulnerable patients. Furthermore, avoid splitting those pharmacotherapies with a narrow therapeutic range, and provide a pharmacist assistance and a splitting device for unavoidable splitting.
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Brustugun J, Birkedal Aas E, Tho I, Bjerknes K. Comparing Two Methods of Tablet Manipulation to Adjust the Warfarin Dose in Paediatric Care. Pharmaceutics 2020; 12:E375. [PMID: 32325777 PMCID: PMC7238213 DOI: 10.3390/pharmaceutics12040375] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 04/15/2020] [Accepted: 04/16/2020] [Indexed: 11/24/2022] Open
Abstract
Tablets containing prescribed doses are not always available, and this is of particular importance in paediatric care where suitable age-appropriate formulations are generally lacking. To obtain a child-adjusted dose, tablets are manipulated in several ways; e.g., they may be dispersed in water before a fraction is extracted, or they may be split before the resulting fragment is dispersed. In this study, the accuracy attained through these manipulation methods was investigated for two generic tablets containing the anticoagulant warfarin. Tablets were dispersed in water (10 mL) before a fraction (10%) was withdrawn, alternatively tablets were split in half or quarter fragments before the fragments were dispersed in water. To investigate the contribution of variability from the different steps in the manipulation processes, the amount of warfarin recovered from the various dispersions was determined, as was the accuracy of the splitting. A validated UHPLC-method was used for quantitative determination of warfarin. Splitting of the tablets could result in deviation >30% from the ideal, theoretical weight. The amount of drug substance extracted as a fraction from the dispersed tablets deviated no more than 10% from the intended amount. To obtain the most accurate child-adjusted fraction dose of warfarin, the tablets investigated in this study should be dispersed and the desired proportion extracted. Practices that involve splitting tablets are likely to increase the variation, and should be avoided.
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Affiliation(s)
- Jørgen Brustugun
- Hospital Pharmacy Enterprise, South Eastern Norway, 0050 Oslo, Norway; (E.B.A); (K.B.)
| | - Elisabeth Birkedal Aas
- Hospital Pharmacy Enterprise, South Eastern Norway, 0050 Oslo, Norway; (E.B.A); (K.B.)
- Department of Pharmacy, University of Oslo, 0316 Oslo, Norway
| | - Ingunn Tho
- Department of Pharmacy, University of Oslo, 0316 Oslo, Norway
| | - Kathrin Bjerknes
- Hospital Pharmacy Enterprise, South Eastern Norway, 0050 Oslo, Norway; (E.B.A); (K.B.)
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Gharaibeh SF, Tahaineh LM, Khasawneh AH. Tablet splitting practice in Jordan. JOURNAL OF PHARMACEUTICAL HEALTH SERVICES RESEARCH 2018. [DOI: 10.1111/jphs.12258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Shadi F. Gharaibeh
- Department of Pharmaceutical Sciences; Faculty of Pharmacy; Jerash University; Jerash Jordan
| | - Linda M. Tahaineh
- Department of Clinical Pharmacy; Faculty of Pharmacy; Jordan University of Science & Technology (JUST); Irbid Jordan
| | - Afaf H. Khasawneh
- Department of Clinical Pharmacy; Faculty of Pharmacy; Jordan University of Science & Technology (JUST); Irbid Jordan
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Ashrafpour R, Ayati N, Sadeghi R, Zare Namdar S, Ayati N, Ghahremani S, Zakavi SR. Comparison of Treatment Response Achieved by Tablet Splitting Versus Whole Tablet Administration of Levothyroxine in Patients with Thyroid Cancer. ASIA OCEANIA JOURNAL OF NUCLEAR MEDICINE & BIOLOGY 2018; 6:108-112. [PMID: 29998143 PMCID: PMC6038971 DOI: 10.22038/aojnmb.2018.26793.1187] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Objectives TSH suppression by Levothyroxine consumption is a mainstay of thyroid cancer treatment. Tablet-splitting is a worldwide approach in dose adjustment in patients. However, it is highly recommended to evaluate the validity of tablet splitting for each distinctive drug by clinical trials before routinely using tablet halves in clinical practice. In this study we compared the effect of 150 µg dose of Levothyroxine by use of a100 and a 50 µg tablets or one and half 100 µg tablets in Differentiated thyroid cancer (DTC) patients. Methods One hundred DTC patients treated with one and half 100 µg Levothyroxine tablets were randomly divided into two groups. The first group continued taking medication as before and the second group received the same daily dose by taking one 100 and one 50 microgram Levothyroxine tablets. The mean changes in TSH and T3 levels and patients weight were compared between the groups. Results 91 patients completed the study. Levothyroxine consumption pattern, age, gender distribution, weight and TSH levels were comparable between groups at the beginning of the study. The mean change of body weights, serum levels of T3 and TSH showed no significant difference between groups in different time points during the study (P>0.05). Conclusion This study showed similar efficacy of tablet splitting and two tablets administration for Levothyroxine; however, patients preferred two tablets at the end of the study. It can be concluded that tablet splitting can be used as an alternative way when the 50 µg tablet is not available.
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Affiliation(s)
- Ramin Ashrafpour
- School of medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Narjess Ayati
- Nuclear Medicine Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ramin Sadeghi
- Nuclear Medicine Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Samira Zare Namdar
- Nuclear Medicine Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Nayyereh Ayati
- Department of harmacoeconomics and harmaceutical dministration, aculty of harmacy, Tehran University of medical sciences, Tehran, Iran
| | - Somayyeh Ghahremani
- Nuclear Medicine Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Seyed Rasoul Zakavi
- Nuclear Medicine Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
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Wójcik-Pastuszka D, Biedrawa AM, Haznar-Garbacz D, Musiał WS. The influence of physical division of tablets on the variability of release kinetics of gliclazide. MONATSHEFTE FUR CHEMIE 2018; 149:953-959. [PMID: 29720769 PMCID: PMC5915509 DOI: 10.1007/s00706-018-2176-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 02/18/2018] [Indexed: 11/30/2022]
Abstract
Abstract Tablets are often used in splitting process when the appropriated, registered dose is not available on the market or patients exhibit swallowing difficulties caused by the size of the tablet. The aim of the work was to assess the impact of physical division of tablets on the kinetics of in vitro gliclazide release from the intact and divided tablets. Gliclazide was released from prolonged release tablets containing 30 or 60 mg of the drug into a phosphate buffer, pH 7.4 and the amount of the drug in acceptor fluid was determined by UV–Vis spectrophotometry. The dissolution profiles were fit to zero- and first-order kinetics as well as to the Korsmeyer-Peppas equation. The largest discrepancy in the values of rate constants was obtained in the case of the release of gliclazide from intact and from splitting tablets using zero- and first-order kinetics. The values of the rate constants k0 obtained from the release of the drug from the intact tablets and from fragments with a dose of the drug of 30 mg were (4.2 ± 0.1) × 10−5 g min−1 and (5.8 ± 0.1) × 10−5 g min−1, respectively, and k1 were (2.3 ± 0.1) × 10−3 min−1 and (4.7 ± 0.6) × 10−3 min−1, respectively. These discrepancies were confirmed by the value of f2 coefficient that was 45.9. The results suggest that physical division of tablets accelerate the release of gliclazide from its prolonged form. Graphical abstract ![]()
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Affiliation(s)
- Dorota Wójcik-Pastuszka
- 1Department of Physical Chemistry, Faculty of Pharmacy, Wroclaw Medical University, Wroclaw, Poland
| | - Anna M Biedrawa
- 1Department of Physical Chemistry, Faculty of Pharmacy, Wroclaw Medical University, Wroclaw, Poland
| | - Dorota Haznar-Garbacz
- 2Department of Drug Form Technology, Faculty of Pharmacy, Wroclaw Medical University, Wroclaw, Poland
| | - Witold S Musiał
- 1Department of Physical Chemistry, Faculty of Pharmacy, Wroclaw Medical University, Wroclaw, Poland
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Nidanapu RP, Tamijarassy B, Mahadevan S, Gitanjali B. Comparative Effect of Divided Doses of Adult Solid and Liquid Oral Formulations of Antiepileptic Drugs in the Management of Pediatric Epilepsy. J Pharmacol Pharmacother 2017; 8:54-61. [PMID: 28706399 PMCID: PMC5497400 DOI: 10.4103/jpp.jpp_7_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective: To compare the differences in the efficacy and safety of the commonly prescribed AEDs in the management of epilepsy in children when using divided doses of adult solid oral formulations (DDSF) with the liquid oral formulations (LFs). Materials and Methods: Patients who had one or more seizures per month and prescribed with DDSF were recruited. Initially the patients were continued on DDSF for 4 months following which they were switched over to LF for the subsequent 4 months. Seizure frequencies and adverse drug effects (ADRs) were recorded every month for 8 months and plasma AED levels were estimated at the end of 4th and 8th months. Results: A total of 200 patients completed the study protocol. The median seizure frequencies per month with DDSF and LF were: partial seizures (20.5, 9.0; P < 0.001), generalized tonic-clonic seizures (6.5, 2.0; P < 0.001), myoclonic seizures (58.5, 29.0; P < 0.001). Mean plasma drug levels ± SD (μg/ml) with DDSF and LF were: sodium valproate (48.2 ± 13.7, 69.1 ± 16.3; P < 0.001), phenytoin sodium (5.0 ± 2.4, 12.8 ± 3.8; P < 0.001), carbamazepine (4.5 ± 2.0, 11.5 ± 4.8; P < 0.001) and phenobarbitone (14.1 ± 5.2, 25.4 ± 12.3, P < 0.001). The incidence of treatment emergent ADRs was poor scholastic performance (25.5%), behavioral problems and dizziness/sedation (21.0%), somnolence/sleep disorders (19.5%). Conclusion: Patients treated with LF had better seizure control and optimal therapeutic drug levels and less adverse effects when compared to DDSF.
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Affiliation(s)
- Ravi Prasad Nidanapu
- Department of Pharmacology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Bascarane Tamijarassy
- Department of Pharmacology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Subramanian Mahadevan
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Batmanabane Gitanjali
- Department of Pharmacology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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Tablet Splitting of Antiepileptic Drugs in Pediatric Epilepsy: Potential Effect on Plasma Drug Concentrations. Paediatr Drugs 2016; 18:451-463. [PMID: 27704404 DOI: 10.1007/s40272-016-0193-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Tablet splitting is the process of dividing a tablet into portions to obtain a prescribed dose of medication. Very few studies have investigated whether split parts of a tablet deliver the expected amount of drug to patients. OBJECTIVE Our objectives were to evaluate the split parts of adult-dose tablet formulations for percentage of weight deviation, weight uniformity, weight loss, drug content, and the content uniformity of four antiepileptic drugs (AEDs) prescribed to pediatric patients. We also measured AED plasma concentrations in the children. METHODS We chose to study first-line AEDs (phenytoin sodium [PHE], sodium valproate [SVA], carbamazepine, and phenobarbitone) as they are routinely prescribed in India. We asked caregivers to perform the same splitting process they follow in their homes on three whole tablets during their routine visit to the outpatient department. After caregivers split the tablets, we studied the weight and content of the split parts. We also used high-performance liquid chromatography to study plasma drug concentrations in children who had received split AEDs for at least 4 months. RESULTS A total of 168 caregivers participated in the study, and we analyzed 1098 split tablet parts. In total, 539 (49.0 %) split parts were above the specified limit of the 2010 Indian Pharmacopeia (IP) acceptable percentage weight deviation (PHE 169 [48.8 %], SVA 187 [51.9 %], carbamazepine 56 [41.1 %], phenobarbitone 127 [49.6 %]); 456 (41.5 %) split parts were outside the proxy IP specification for drug content (PHE 135 [39.0 %], SVA 140 [38.8 %], carbamazepine 51 [37.5 %], phenobarbitone 130 [50.7 %]), and 253 split parts were outside the acceptable content uniformity range of <85 % and >115 % (PHE 85 [24.5 %], SVA 98 [27.2 %], carbamazepine 14 [10.2 %], phenobarbitone 56 [21.8 %]). In total, 130 (72.2 %) patients had plasma drug concentrations outside the therapeutic range (PHE 36 [72.0 %], SVA 39 [78.0 %], carbamazepine 34 [68.0 %], phenobarbitone 21 [70.0 %]). CONCLUSIONS Splitting adult-dosage formulations of AEDs results in patients not receiving the optimal dose. Plasma drug concentrations are also not optimal. Pediatric dosage formulations should be preferred to splitting adult-dosage formulations in pediatric epilepsy.
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Evaluation of Certain Pharmaceutical Quality Attributes of Lisinopril Split Tablets. Sci Pharm 2016; 84:646-653. [PMID: 27727195 PMCID: PMC5198024 DOI: 10.3390/scipharm84040646] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 07/28/2016] [Indexed: 11/17/2022] Open
Abstract
Tablet splitting is an accepted practice for the administration of drugs for a variety of reasons, including dose adjustment, ease of swallowing and cost savings. The purpose of this study was to evaluate the physical properties of lisinopril tablets as a result of splitting the tablets either by hand or with a splitting device. The impact of the splitting technique of lisinopril (Zestril® tablets, 20 mg) on certain physical parameters such as weight variation, friability, disintegration, dissolution and drug content were studied. Splitting the tablets either by hand or with a splitter resulted in a minute but statistically significant average weight loss of <0.25% of the tablet to the surrounding environment. The variability in the weight of the hand-split tablet halves was more pronounced (37 out of 40 tablet halves varied by more than 10% from the mean weight) than when using the tablet splitter (3 out of 40 tablet halves). The dissolution and drug content of the hand-split tablets were therefore affected because of weight differences. However, the pharmacopoeia requirements for friability and disintegration time were met. Hand splitting of tablets can result in an inaccurate dose and may present clinical safety issues, especially for drugs with a narrow therapeutic window in which large fluctuations in drug concentrations are undesirable. It is recommended to use tablets with the exact desired dose, but if this is not an option, then a tablet splitter could be used.
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