Many people split their pills for various reasons, from attempting to save money to being unable to swallow, especially if they are older adults or have had a stroke (dysphagia).
One study suggests that 1 in 4 people cut their pills in half.
As a geriatric pharmacist, I see this a lot in my patients.
So, since this is a common practice, you probably think there is no harm when you cut Eliquis in half.
Well, not exactly – you have to do it the right way.
If you don’t, you risk uneven dosing of your Eliquis.
This can then lead to potentially subtherapeutic dosing, resulting in an increased risk of stroke and hospitalization.
In this article, we’ll delve into the formulation of apixaban tablets, FDA regulations and guidelines surrounding their use, and the potential consequences for you if you cut your medication in half.
But first, I know some of you want the answer quickly. So, here it is:
Can you cut Eliquis in half?
Yes, you can cut Eliquis (apixaban) in half, but you must ensure that you cut them evenly without disintegrating them.
To understand why, I encourage you to keep reading…
The formulation of Eliquis tablets
When examining the composition of Eliquis tablets, you’ll find that they are film-coated and contain specific inactive ingredients designed for proper absorption by your body.
The film coating ensures the medication is protected from humidity and heat.
Also, Eliquis by itself has a very bitter taste, and the film coating helps to make the drug easier to take orally.
When you cut Eliquis in half, the film coating is damaged.
However, this does not affect the medication’s efficacy from a therapeutic standpoint.
When you cut Eliquis in half, it won’t necessarily alter its absorption rate, but rather, may cause uneven distribution of the active drug if the person doing the cutting is not careful and precise, leading to decreased efficacy or even harmful adverse effects.
FDA Regulations and Guidelines
In this section, we’ll dive into the FDA’s stance on splitting and crushing Apixaban tablets, shedding light on regulations and guidelines surrounding the practice.
The FDA provides oversight to ensure that medications are safe and meet regulatory compliance requirements.
Regarding tablet-splitting practices, the FDA acknowledges that some tablets are scored, meaning they have a line down the middle to facilitate cutting them in half.
However, not all medications can or should be split, as doing so may alter their effectiveness or cause adverse effects.
For Eliquis specifically, the FDA doesn’t really say or recommend splitting the tablets (I will explain more in the next section below).
How do you know if you can cut Eliquis in half?
In most instances, scored pills can be cut in half since the manufacturer formulated it this way.
Even then, always check with your doctor or pharmacist.
Because the information gets confusing and contradictory, depending on the medication you are looking at.
For example, metoprolol succinate, a commonly used extended-release medication for the heart, can be cut along its score mark, BUT it cannot be crushed or chewed.
Another example is Sinemet CR 50-200 mg tablets, a medication used to treat Parkinson’s Disease.
Although it is an extended-release formulation, it can be cut along its score mark.
Just like metoprolol, it cannot be crushed or chewed.
However, most other extended-release pills cannot be cut…Confused yet?!
But, there is guidance…your doctor and pharmacist are always your go-to sources for accurate drug information.
If you cannot talk to them but need immediate assistance, there is a resource you can consult – google your medication’s package insert and scroll down to the “How Supplied” section.
Many manufacturers will state here if the U.S. Food and Drug Administration (FDA) has approved the drug for splitting.
If you don’t see any information about splitting tablets in this section, it means that the FDA has not evaluated it fully.
This is the case for Eliquis.
Read the FDA’s Best Practices for Tablet Splitting for more information.
So, what does this mean?
Do you cut Eliquis in half or not?
Yes, you could technically cut Eliquis in half.
However, based on my clinical experience, my stance is not to do it.
Apixaban comes only in 2.5 and 5 mg strengths.
Most people will be prescribed the standard dose of 5 mg twice daily.
The only likely scenario where you would need to take 2.5 mg twice daily is if you are at least 80 years old and either weigh 60 kg or less or have a serum creatinine level (blood test used to measure kidney function) greater than 1.5 mg/dL (133 micromole/L for our friends using SI units).
If you belong to this latter group of people, I suggest verifying with your doctor that they will prescribe the 2.5 mg tablet.
However, I understand this may not always be possible because receiving the 5 mg tablets, which can then be split, may be more cost-effective for you.
Either way, it is worth exploring all options.
How to cut a pill in half?
If your pill can be split, there is a proper way to do it. Here are some tips for pill splitting:
- Use a specialized pill cutter like this one. The blade is sharp and cuts the pill evenly.
- Press down to cut quickly! Doing it slowly will crumble the pill.
- Only cut one pill at a time! The moment you cut into it, atmospheric moisture and heat will begin degrading it.
- Use clean hands! Don’t want your pills to become contaminated! (Don’t forget to clean your pill cutter too! – can use 70% isopropyl alcohol to wipe down and let it dry completely).
- DON’T use a butter knife, your teeth, or your fingernails to split your medication! Yes, I’ve seen this! It won’t yield a clean cut – Use a proper pill cutter.
- NEVER assume your pill can be cut – ALWAYS check with your doctor or pharmacist (Yes, I’m repeating this, but it’s for a good reason).
Risks associated with pill splitting
These are the reasons why I don’t generally like splitting pills.
This is especially important from my perspective as a geriatric pharmacist working with older adults who are at risk for medication-associated adverse effects.
The reasons for this are many and outside the scope of this article.
The most common risk is improper or inaccurate cutting of the pill. If you have cut pills before, you know what I mean.
It’s not that easy!
Improper cutting can lead to under-dosing or overdosing on your medication:
- Splitting accuracy.
- Uneven tablet halves: If the tablet isn’t divided precisely in half, one dose may be too high and another too low, leading to inconsistent blood thinning effects.
- Inaccurate dosing: A lack of splitting accuracy could result in taking more or less than the prescribed dose, increasing the risk of bleeding or clotting complications.
This study found that close to 1 in 8 split pills were inaccurate more than 20% of the time!
Depending on the type and strength of the pill in question, the consequences can be serious!
Can Eliquis be crushed?
Just as Eliquis can be cut, it can also be crushed and safely administered.
The FDA validates this in its prescribing information for Eliquis.
In section 2.6 on page 6, under “Administration Options,” the FDA states:
“For patients who are unable to swallow whole tablets, 5 mg and 2.5 mg ELIQUIS tablets may be crushed and suspended in water, 5% dextrose in water (D5W), or apple juice, or mixed with applesauce and promptly administered orally. Alternatively, ELIQUIS tablets may be crushed and suspended in 60 mL of water or D5W and promptly delivered through a nasogastric tube. Crushed ELIQUIS tablets are stable in water, D5W, apple juice, and applesauce for up to 4 hours.”
This is drilled into every pharmacy student’s brain in pharmacy school – water or moisture is every drug’s greatest enemy, contributing to its ultimate degradation and loss of stability and therapeutic benefit.
So, if you do decide to crush the drug and mix it with a liquid, it must be taken within 4 hours.
DO NOT STORE IT FOR USE LATER!
Yes, you can cut Eliquis in half, but pay close attention to how carefully you cut the tablet and what tool you use!
Better yet, ask your doctor if they would prescribe the right strength of Apixaban for you, so you don’t have to mess with cutting your own tablets.