Tapering Meds / Pill Cutting [Archive]

sandie

31-12-15, 09:04

Some of you will know that I am tapering down my Mirtazapine - having started on 30 mg and now down to 7.5 mg.

It is common knowledge that withdrawing from meds should ideally be done very slowly, gradually and in small increments; all my research shows that 10% reduction is the suggested and preferred amount for each reduction,

When I told my GP I wanted to withdraw from 30 mg, he told me to just drop down to 15 mg for a couple of weeks, and then 15 mg on alternate days for another couple of weeks before stopping completely.

I mentioned about cutting pills and was told that because the Mirtazapine tablets are only available in 15, 30 and 45 mg (ie, increments of 15 mg), then he can only recommend increases and reductions in these increments, and he cannot 'condone' or 'suggest' cutting pills.

I was lucky because although I had never used the 45 mg prescription, I was able to have this dispensed so that I could cut one tablet in half to 22.5; from here I dropped to 15 mg and I am now on 7.5mg.

I know I have rambled a bit here, but now I come to the point I want to make. Last night when cutting my 15 mg in half (and there is a clear vertical line down the middle of the pill which is obviously intended to aid the pill being divided), I happened to notice a similar small horizontal line on one half of the pill - no doubt there to aid cutting the pill further - ie, into 3.75 mg.

I am baffled why it is that the drugs manufacturers mark the pills in such a way, and yet GPs are reluctant to advise pill cutting.

I know that in the US and I suspect some parts of the UK, liquid meds are available in order to facilitate very gradual withdrawal, but this is very expensive.

MyNameIsTerry

01-01-16, 06:40

I've been looking into this for a friend who is pill cutting as their GP said it wouldn't work because it wouldn't be "evenly distributed" meaning the active drug wouldn't be spread evenly across the whole pill. Some Googling to find studies proving it under testing conditions for a range of antidepressants including this person's med proved that GP wrong.

Some things I found out:

- The German medical system approves of it and practices it per guidelines on which meds to do it on.
- Manufacturers actually put the split like there to allow it to be done, hence they approve that the med is suitable for cutting. This means it has been homogenized.
- In the US, there are laws stating generics must match the branded ones.
- There are studies promoting pill cutting as safe & accurate.
- There was a study the NHS explained showing 3 methods (pill cutter, scissors, kitchen knife) but the sample size was truly pathetic (5 meds, 8 pill total tried)
- A pill that is "film coated" means nothing as that's to avoid the bad taste or to protect the med from bacteria/discolouration in storage.
- A pill that is "enteric coated" must not be cut as either this is to protect your throat/stomach from irritation AND/OR to allow the pill not to be digested in the gut but to reach the small intestine first.
- A pill that is "timed-release" should NEVER be cut because it will disturb the timed-release element and could cause the whole dose to be absorbed straight away possibly causing an overdose.
- Pills tend to have a bottom layer with the active drug in and the fillers & binders above so only cut through the pill top-to-bottom, never along the layers in a side-to-side motion.
- Knife cutting has been seen to be more accurate than pill cutters in some circumstances.
- The structure of the pill affects the outcome in terms of accuracy based on whether it crumbles or crushes as opposed to getting a clean cut.
- Loss of active drug due to crumbling or crushing could be a problem so you have to factor this in to avoid your doses being uneven.
- Medical professionals have better methods of course and will also weigh the cut sections to ensure accuracy (or should do). So, how about buying a cheap jewellery scale off Ebay for <£3 which go from 0.01-100g? Then you know for sure and could add the crumbled bits on at the worst if a cut section is less than the others. With a scale like this you can weigh each piece to determine how close they are to the real overall pill. Remember though, weigh the pill first, don't go by the manufacturer in case there are slight differences or if the dose doesn't include the fillers & binders in the weight (which is probably won't)
- Long half life drugs with a wide therapeutic range are seen as pretty safe for pill cutting according to a NHS report, whether they have a split line or not.
- Some manufacturers put 2 split lines, then 1 in the middle. The 1 in the middle is the one to use.
- Even if a split line isn't included it doesn't mean they can't be split in theory. However, you would need to ensure the med has been homogenized as this makes it evenly distributed.

I can probably add more but that's all that springs to mind right now without checking what I sent to my friend.

So, pill cutting is perhaps more complex than we tend to talk about it on here. There are some dangers e.g. don't ever split Ven XR. There are also some ways you can improve this with weighing and a scale is very cheap (I've bought one myself as I'm making my own supplements up as it's cheaper than buying them and no fillers/binders in them either).

If that doesn't convince you, think of it from another angle. Your GP will ONLY allow you to withdraw based on what the manufacturers make. So, this can mean switching back & forth between branded & generics which does cause a problem for some. And your GP may have no choice but to withdraw you at 50% each time which contradicts the advice the charities like MIND give as well as people like Rpsych who are made up of the very people our GP's refer us to, the psychiatrists!

So, going back to sandie's GP for a minute. He won't condone it or condemn it. This is because the medical world is still "split" (:winks:) on the issue. Ok, we have HMO's in the US doing it, uni studies proving it safe and several countries doing it as standard e.g. Germany. Safe enough for us then? Certainly more has gone into assessing the safety of this than the opinion, or lack of, of one GP.

Sandie's GP wants to subject her to a 50% withdrawal, just like mine did. I was ok coming off Citalopram but I was at a good recovery point by then. I wouldn't condone that if you are struggling as it could hit you much harder.

So, the choice is - stick with the GP (who to be fair can't say eitherway as the NHS haven't decided yet) and experience a 50% withdrawal OR cut the pill, maybe lose a tiny amount and reduce at a less impacting 10%. Even if you lose part of that med, how much do you think it will impact you? As much as that extra 40% the GP wants to go with? Even if you crush & lose some of it, remember the pill is loaded with non active agents so you aren't losing that whole chunk in your med. So, is it really going to be 40% worth? Just be careful and try not to lose hardly any and if you really want to be sure on that, look up the acceptable loss % because there is one and manual pill cutting can easily fall inside tolerance...otherwise all those medical professionals couldn't dfo it either :winks: