Splitting Coumadin tablets - NO NO or OK????

[slipkid]

I'm getting conflicting advice, and reading conflicting information now as I research this on the 'net, regarding whether it is bad vs. OK to split Coumadin tablets in order to get a "half-dose".

I am on 5mg daily but while post-op early on (while still in the surgeon's care) was told to up that to 7.5mg. I asked the P.A. at the time for a 'scrip for 2.5mg so I could add those to my 5mg pills that but he told me to just break apart the 5mg capsules on the score line to get the additional 2.5mg.

However my sister who used to be a nurse, and her husband who has been on coumadin for about 8 years, tell me that splitting these pills should most certainly NOT be done. They say that when splitting it is impossible to cut them 100% accurately, and you will end up with more or less than 2.5mg in each side if doing this. Also that the medicine in the pill is not necessarily "evenly distributed" in the first place across the pill so even if I were to magically split it perfectly in "half" that doesn't guarantee the halves actually have 50% of the medicine in them. Logically what they are saying makes sense to me but it could be hogwash too. Before I raise this as an issue to my current cardiologist I'd like to get educated more myself (I now am supposed to take an extra 2.5mg once a week but hadn't asked this doctor yet if it is OK to split or not).

What do YOU know about splitting coumadin? Yes vs.no and if no why not?





.

 

[Freddie]

What your sister says makes sense.

Going from 5mg to 7.5mg is rather a big jump in dosage. What was your last INR result?
Speaking for myself (and maybe a few others) a slow increase in dosage of 5% is better than making a large increase. Otherwise you may find yourself on a 'roller coaster' ride.

If I was in your shoes, I would just take 7mg and not worry about the extra half and see where that takes you after a week, then if need adjust dosage again.
Who knows, in the future you may find yourself alternating days from 7mg to 8mg or 6mg to 7mg to be in that happy INR range.

I wouldn't fret it and I wouldn't spilt the pills.

 

[slipkid]

What your sister says makes sense.

Going from 5mg to 7.5mg is rather a big jump in dosage. What was your last INR result?

2.0 - That is on 5mg a day with one day at 7.5mg.

Recommended range for my valve is between 2.0 and 3.0.

The test prior to the current one had my INR at 2.4 btw. But it seems to me that I probably spike up way higher once the 7.5mg is in my system then it gradually decays down during the week.

Speaking for myself (and maybe a few others) a slow increase in dosage of 5% is better than making a large increase. Otherwise you may find yourself on a 'roller coaster' ride.

If I was in your shoes, I would just take 7mg and not worry about the extra half and see where that takes you after a week, then if need adjust dosage again.
Who knows, in the future you may find yourself alternating days from 7mg to 8mg or 6mg to 7mg to be in that happy INR range.

I wouldn't fret it and I wouldn't spilt the pills.

Thanks but the only pills I have, or have a prescription for, are 5mg.

So I currently have no option to take 7.5mg unless I split the pills.

I was taking 5mg a day but they now want me to take 7.5mg on one day of the week since consistently at 5mg my INR has been too low (less than 2).

For me to take 7.5mg I either need to split the 5mg pills so I can add a half pill to my normal 5mg or get a prescription for 7.5 (if such a thing exists), or get a prescription for 2.5mg to add to my existing 5 mg ones.

I'm trying to find out if splitting the pills is really recommended or not. Because if not then I want to mention this to current doctor to raise the issue that I want to get pills of proper dosages so I do not have to split anything.

Thus far I have been learning that the various doctors & physician assists I see do not necessarily agree, or even know, what each others are telling me btw. This has come up in many areas already. For example regarding INR/coumadin when I told my primary MD that the cardio assistant was telling me to take 7.5 on one day each week he said something like "that isn't how we would do it, we would have you mix 5mg for 4 days and 6mg for 3 days etc". However he went on to say that he was "OK" with how they were doing it. To me it makes more sense to spread the larger dose out but...I am caught in the middle. Before I upset too many applecarts to "suggest" a better way of treatment I want to understand more about all of this...

Also note that I have no way to get tested each week anymore (I used to get tested twice a week, then once a week). But the cardiologist's assistant moved me to two weeks between testing and now wants me to spread it out to a month!!! I think he has no idea what he is doing btw.

 

[MrsBray]

I g to a Coumidin Clinic at my cardiologists office. The RN that I see every time i go there (every 2-3 weeks for now) ONLY does warfarin testing. She has never mentioned anything to me about not splitting pills. I started on 5mg/day after surgery, then moved up to 7.5/day when my levels didn't improve. Then I was moved up to a mix of 10/day & 7.5/day, with no other prescriptions given. She asked is I had a pill splitter, and nothing else was mentioned. Maybe I'll ask her next week when I'm in.

 

[slipkid]

I g to a Coumidin Clinic at my cardiologists office. The RN that I see every time i go there (every 2-3 weeks for now) ONLY does warfarin testing. She has never mentioned anything to me about not splitting pills. I started on 5mg/day after surgery, then moved up to 7.5/day when my levels didn't improve. Then I was moved up to a mix of 10/day & 7.5/day, with no other prescriptions given. She asked is I had a pill splitter, and nothing else was mentioned. Maybe I'll ask her next week when I'm in.

Thanks, please ask and report back.

Googling around about this I've seen some text that says to NOT split Coumadin/Warfarin pills but others that make no mention of splitting being a problem at all.

This thread has brought up another point I want to ask about, something relating to what Freddie said above. Maybe I should start a whole 'nother thread the issue of taking ONE day with a 50% dosage bump as opposed to spreading it out more evenly...actually think I will do that right now...

 

[pellicle]

Hi

What do YOU know about splitting coumadin? Yes vs.no and if no why not?

the drug makers place a line in the tablet to enable splitting. They do this because they are confident that if you split it along that line you'll get half the entire pills dose. I regularly split my pills. For instance I will split 3mg and 1mg and add that to a 5mg when I want 7mg. Pharmacists and hospitals do it all the time here too.

Even IF your splitting is off marginally it can not be as off as taking 5 mg then 8 mg in some stupid confusing sequence of "take X on monday, wed and friday, with Y on the other days and Z once".

Even if you split a tablet (say a 3mg) into 1.6mg and 1.4mg) then you'll take both parts in the coming days, so what's the diff? IF they are so worried about the minuscule daily differences when you split the tablet then why would they then advocate >1mg daily variations. Its illogical.

Best Wishes

 

[slipkid]

Hi



the drug makers place a line in the tablet to enable splitting. They do this because they are confident that if you split it along that line you'll get half the entire pills dose. I regularly split my pills. For instance I will split 3mg and 1mg and add that to a 5mg when I want 7mg. Pharmacists and hospitals do it all the time here too.

Even IF your splitting is off marginally it can not be as off as taking 5 mg then 8 mg in some stupid confusing sequence of "take X on monday, wed and friday, with Y on the other days and Z once".

Even if you split a tablet (say a 3mg) into 1.6mg and 1.4mg) then you'll take both parts in the coming days, so what's the diff? IF they are so worried about the minuscule daily differences when you split the tablet then why would they then advocate >1mg daily variations. Its illogical.

Best Wishes

Thanks very much. That is the kind of feedback I'm looking for

At this point I am less concerned about splitting (and the objections insistently raised by my sister & bro-in-law) than I am about taking the extra 2.5mg in one shot instead of spreading the dosage around all week. I've started a different thread on that. I've heard conflicting opinions on that one too...

 

[DebbyA]

Like others, I split a tablet using the scoring across the middle to get the prescribed dosage, and do it on the cardiologist's recommendation. If they were capsules, it would be different because it would indeed be difficult to halve the contents.

 

[tom in MO]

The pills are designed to be split. I was told thic by my coumadin clinic and i've read it in the drug product information i read about two years ago.

 

[dick0236]

I agree with most of the others. My understanding is that any pill that is scored can safely be split.

 

[Aggie85]

Slipkid, I think we've established it's ok to split them. That was going to be my input as well. Infact, my pharmacist wrote a script for a pill splitter when she added the 2mg pills to my at home formulary. I did notice more with my LoPressor, also being split, that even with the score line, they don't always break even. What I did was take all the halves and divide them evenly among the doses. Example, I take 1/2 LoPressor 3x / day. I took all the smallish "halves" and put them in the pill holder slots for the mid-day doses thru the week. All the somewhat larger ones for first in morning, and evenly divided ones for the evening doses. This divided out the dosages evenly thru the day and the week overall. It will be harder to do this with not so many times to divide out uneven pills since Coumadin is only 1x/ day but you get the idea. Also, I found the Coumadin divide more evenly than the tiny LoPressor pills do.

What I'd like to add is a comment about all the conflicting information you're getting from the various offices (cardio, ACClinic, ...). When I was moved from my cardio managing my coumadin to the clinic doing it, there became a very definite break point as to who was doing what. In fact, there was an issue during the couple hours between when the two offices exchanged responsibility, my cardio told me to wait for reply from ACC so there wouldn't be confusion between who was telling me what. Once in ACClinic THEY took over COMPLETE management of my Coumadin regime. They said this was to give clear command and control (yeah this is on a military base ) as to who was responsible (hence legally liable) for my care and to avoid my getting conflicting advice. My cardio has basically been hands off in regards to the Coumadin since then. While it may be the military way of compartmentalizing care, and things in general, it also makes a lot of sense. I would suggest that you pick which office you think is managing your coumadin the best and then have ONLY them do it.

I'm also surprised that as fresh postop as you are, and since you're still not really stable, that they're moving you to once a month already. I remember you having insurance issues, is there a copay problem or insurance problem that they're using as excuse to be pushing you out so fast? Not meaning to be prying, but if you can, I'd again recommend you simply tell them you're not comfortable moving out to once a month while they're still making medication changes and while you're levels haven't stabilized.

What ever came of the home monitoring issue? I assume you never got the machine?

Best of luck and if so needed; SPLIT THOSE PILLS BABY! :thumbup:

Linda

 

[Freddie]

Slipkid,
you need to get a prescription for 1mg of warfarin

 

[slipkid]

I'm also surprised that as fresh postop as you are, and since you're still not really stable, that they're moving you to once a month already. I remember you having insurance issues, is there a copay problem or insurance problem that they're using as excuse to be pushing you out so fast? Not meaning to be prying, but if you can, I'd again recommend you simply tell them you're not comfortable moving out to once a month while they're still making medication changes and while you're levels haven't stabilized.

No insurance or copay problems as far as that being a reason for less testing. The insurance issues I have had were the mess of trying to get Home INR testing, and several billing problems that I had to fight to get processed correctly.

From my perspective they are simply pushing me out to one month because "that is the way we do this" kind of thing. I told them I am not comfortable with that yet. I honestly do not believe that they really know what they are doing. According to them I am "stable" since my last 2 tests were 2.4 and 2.0 so that means I should go out to a month.

But I am very wary how they are "managing" my warfarin by having me take a 50% higher dosage (7.5mg) one day a week as opposed to spreading that extra 2.5mg out across the entire week. They appear to have no knowledge of this not being a recommended way of doing things (am I wrong on this??). I have created a different thread on this topic asking for opinions. I don't want to cause a fuss but on the other hand I want to be managed/monitored in the best possible way. From what I'm seeing I do not believe that is the case though.

What ever came of the home monitoring issue? I assume you never got the machine?

I still don't have that yet. I am still trying to get it. I dropped off the form for a service that BC/BS *thinks* will take my insurance to the doctor office last week. I don't believe I have been "stable" for 3 months yet though.

 

[Protimenow]

Personally, I would NOT be comfortable with once monthly testing. It's lunacy. (My anticoagulation clinic also does monthly blood draws, but I have my own meter - bought on eBay - and I test weekly or, at least, every 10 days to two weeks).

You got bad advice to spike your dose ONE TIME EACH WEEK and to expect this to properly handle your INR.

If possible, take the SAME dose each day. (If you have to add 2.5 to you WEEKLY dose, get some 1 mg pills and split them in half, or some .5 mg pills, and take then five days a week (maybe skipping on Tuesday and Friday, or Monday and Thursday, or something like that). You really DON'T want a large spike once a week. It'll make your INR PEAK for a day or so, then DROP for a few days (possibly even into a dangerous level). Even if it takes a week or more to form a dangerous clot, and your INR will only be too low for just a couple days, it's probably not worth the risk.

If you take that large extra dose on a Sunday, then get your monthly test on Tuesday, the doctor will probably tell you that your INR is TOO HIGH and have you stop taking the extra dose. If you go in on a Friday, with your INR probably around 2, your doctor may have you take ANOTHER EXTRA DOSE.

My advice -- if you can afford it, get your own meter (they're available on eBay). Personally, I'd avoid an InRatio -- in my testing, the results are often too high, and with recent recall issues, strips may be hard to get. CoaguChek XS is a better choice. I prefer my Coag-Sense to either of those, but it may be somewhat harder to find at a good price. (I have a second, new meter. If you're interested, PM me). The ProTime and ProTime 3 meters are also pretty accurate, probably relatively inexpensive on eBay, but a bit harder to test with than the other meters.

From the sounds of it, you really have to take control of your INR management -- you can maybe let that clinic THINK that it's doing you some good -- but it's your life and you'll have to be responsible for maintaining an appropriate INR. (I go to a clinic. They test my blood monthly. I see them every three months. They know that I self-test. The only reason I still let them do blood draws is to confirm that my meters give me results that are pretty close to the lab. Oh, not all labs can give you an accurate INR, either).

I agree with the others regarding splitting -- one caveat: if you split your pills while standing over the floor (like I used to do in the bathroom), be careful not to let any of the particles fall on the floor if you have small animals. A few years ago, one of my dogs apparently picked up some warfarin 'dust' on her feet, licked her feet, and wound up with a minor nosebleed. If the pills weren't meant to be split, they wouldn't be scored to allow this -- and, if I recall, early marketing materials for coumadin promoted the benefit of being able to carefully adjust a dose by SPLITTING the pills - and this is one of the reasons that they offered them in ranges from .5 mg up to 10 mg.

 

[marc_kowal]

My wife works for a large Pharma company , and had this info regarding the score lines on pills. The score line can be used to split a pill for the ease of swallowing it, or it can be used to provide two equal (within reason) half doses provided that the product insert specifically states this.

I checked with my cardiologist and pharmacist a long time ago, and they both told me a it was ok to split my 3mg Warfarin pill.

 

[T in YVR]

Split away! Right now I am taking 8.75 mg daily. I take a 5mg, 2mg, 1mg (whole tab) and then split a 1mg in half, and then split it again to get the 0.75. I have had no issues doing this. Sure, its not *exact* every time, but over the course of a week it balances out and the variation in warfarin consumed is very very minor for me. I take 0.75 metoprolol 2x per day and split that too...I ordered up my warfarin in a bunch of sizes and will look into 0.5 mg next time I need a refill, as well as the 2.5mg. I like having all dosage sizes available because your daily dosage will vary sometimes, and if I can avoid splitting then great.

ProTime is right - taking a large increase 1x per week makes no sense...and testing 1x per month is not for me. I thinks its just wrong - you have no insight when your INR changes or goes out of range. Right now, I home test every week and go to the lab once every couple weeks or so, since its still fairly early post op for me. And self-managing your INR dosage is not rocket science. If you are proactive/involved in your own health care, its the way to go I think (assuming a person can afford to home test or has a plan that covers it). Frankly, I do a way better job than my doctors did with it - I know more about what eat daily, how much I exercise, what other drugs I may take periodically, natural supplements I take, when I get sick (but don't need to see my GP), etc - and after a while you simply have much more daily insight into your own body and what's going in it than your doctor does. All they really see are INR numbers, and then make corresponding dosage requests/changes. However, if you are elderly and/or in poor health or have alot other complications etc, then perhaps its more practical to have your doctor assist with INR management (but monthly is still too long IMO). Just my $0.02.

Tony

 

[T in YVR]

By the way, if your INR is at 2.0 and your range is 2-3 (based on currently taking 5mg daily + a 1 time weekly dosage of 7.5mg), if it were me, I would simply increase my daily dosage by 0.5 mg (up to 5.5 mg every day) and see if it gets my INR up slightly higher, since you are at the bottom of the range - and I would cut out the 1 time 7.5 mg dose - just keep your dosage constant if you can). You would be consuming 38.5 mg per week (7 x 5.5) instead of your current 37.5mg ((6 x 5)+7.5) .......but you have to split more, unless you have 2.5 mg tabs

 

[clay_from_nj]

I've always been on 7.5mg daily with 5.0mg tabs. With my very first warfarin prescription I was given a pill splitter. My anticoag pharmacist will actually specify "one and one-half tablets". I think I'm okay.

 

[slipkid]

Thanks for all the responses.

Seems to me that pill splitting is OK after all.

However I'm afraid that I need a new cardiologist, someone actually familiar with real INR testing and management instead of my current Dr.'s office. I have an appt. with them tomorrow to discuss some things and will try bringing all this up. Wish me luck.

 

[pellicle]

Hi

...but you have to split more, unless you have 2.5 mg tabs

For some reason people seem unaware of the diversity of tablet sizes available.
I use Marevan, but I see that Coumadin comes in the variety of sizes too

FWIW I have tablets in 5, 3 and 1mg so that I can get close to my dose. Perhaps its a bigger investment in having more on hand. At 11 Euro for a bottle of 100 tablets (same price for each dose) it means I perhaps spend 4 Euro a month more than I need to.