# Tablet Scoring: Current Practice, Fundamentals, and Knowledge Gaps
## 4 Tablet Scoring
### Tablet Splitting: Current Practice  
Oral solid dosage form medications, mainly tablets, are prescribed to patients as the most commonly available dosage strengths. As previously indicated, tablets contain a determined amount of drug substance that is designed to provide a desired therapeutic efficacy. Also included in tablet formulations are inert excipients, which are bulking agents, fillers disintegrants or other specialized and non-conventional excipients [85]. In general, tablets dissolve in the stomach and absorb in the lower GI track. In order to prevent tablets to dissolve in the stomach, an enteric based coat is applied. The function of this enteric coating is to provide: (1) protection to the gastric mucosa from irritation or other resulted adverse reactions, and (2) protection to the drug substance so as to prevent eventual degradation due to the pH environment in the stomach [86]. The decision to apply an enteric coat to tablets is typically decided during pre-formulation phase and/or upon gathering preliminary human PK data during early clinical studies. Tablets are also available as controlled release. Controlled release tablets are designed to continuously deliver the dose over an extended period of time [86]. These types of tablets are formulated with polymers of various viscosities that are used to modulate their release profiles [86]. The administration of these tablets is less frequent compared to those of conventional formulations. Splitting tablets in two or, in some cases, multiple fractions had been a common practice both in healthcare institutions and among patients at home. While tablet partitioning has become a common practice globally, especially in pediatric and geriatric population, this concept is still insufficiently investigated [78; 84]. Many marketed tablets are embossed with a scored line to facilitate splitting [87] as shown in Figure 2. For the most part, tablet characteristics dictate the geometrical location of the scored line. Tablets are generally scored for the following reasons:  
1. Facilitate administration. Several factors can influence a patient's inability to swallow a large tablet: dysphagia or difficulty swallowing, patients in moribund state, age-related psychological changes, pediatric patients [88; 89]. 2. Reduce cost and adjust dose. When a higher therapy dose is no longer needed, patients split tablets to save cost. The price variation among different tablet strengths is typically minimal. Requesting a higher dosage tablet strength in order to partition the tablets can be more economical to some patients. Recent studies suggest that the practice of splitting tablets has become more common because of economic hardship [90]. 3. Facilitate dose alteration. Dose alteration involves changing the marketed dose to achieve a target dose, hence, dose tapering or dose titrating [91]. Dose tapering refers to starting a medication at a high dose and slowly decrease the dose to wean the patient out of the medication. Dose tapering is typically done to prevent the effect of medication withdrawal [92]. Medical withdrawal often is associated to clinical adverse reactions. Dose titration refers to starting a medication at a low dose and slowly increasing the dose to the target level [93]. Tablet splitting provides proper dosage in cases where slow dose titration and dose tapering are necessary, particularly with medicines that control the central nervous system [94]. Recently, it has become more of a practice for pharmaceutical companies to manufacture tablets of multiple dose strengths. In some cases, a lower desired dose strength may not be available, thus the need to partition a larger dose tablets into smaller doses. 4. Overcome changes in insurance policies. This practice aligns with cost savings; the down turn of the economy has mas made it a more common practice. Some insurance companies have denied payments for lower-strength tablets, which requires patients to obtain a larger dosage and then split the tablets [90].