Tramadol Hydrochloride

Pronunciation

Class: Opiate Agonists
VA Class: CN101
Chemical Name: (±)-cis-2[(Dimethylamino)methyl]-1-(3-methoxyphenyl) cyclohexanol hydrochloride
Molecular Formula: C16H25NO2•HCl
CAS Number: 53611-16-8
Brands: Ultram, Ultracet

Introduction

Synthetic, centrally active analgesic;1 2 3 4 5 15 53 not an opium derivative or a semisynthetic derivative of morphine or thebaine.1 21 22 53

Uses for Tramadol Hydrochloride

Pain

Management of moderate to moderately severe pain.1 2 3 4 6 7 10 11 16 Efficacy established in patients with moderately severe acute or chronic pain, including postoperative, gynecologic, obstetric, and cancer pain.1 2 3 4 6 7 10 11 16 20

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Extended-release tablets are used for the management of moderate to moderately severe pain when continuous, around-the-clock analgesia is needed for an extended period of time.53 Efficacy established in patients with moderate to moderately severe chronic pain associated with osteoarthritis.53 54

Used in fixed combination with acetaminophen for short-term (≤5 days) management of acute pain.51

Tramadol Hydrochloride Dosage and Administration

Administration

Oral Administration

Administer orally alone or in fixed combination with acetaminophen.1 51 53

Conventional Tablets

Administer without regard to meals.1

Extended-release Tablets

Administer once daily in a consistent manner relative to food intake.53

Swallow tablets whole; do not crush, chew, or split.53

Fixed Combination with Acetaminophen

Manufacturer makes no specific recommendation regarding administration with food.51

Dosage

Available as tramadol hydrochloride; dosage expressed in terms of the salt.1 51 53

Adults

Pain
Conventional Tablets
Oral

Initially, 25 mg daily in the morning; titrate dosage slowly to reduce risk of adverse effects.1 Increase dosage in 25-mg increments as separate doses every 3 days to a dosage of 100 mg daily (25 mg 4 times daily);1 then may increase total daily dosage by 50 mg every 3 days as tolerated, up to 200 mg daily (50 mg 4 times daily.)1 After titration, 50–100 mg can be given every 4–6 hours, up to 400 mg daily.1

If more rapid onset of analgesia is required, may initiate therapy at 50–100 mg every 4–6 hours (up to 400 mg daily), but risk of adverse events may be increased.1

Extended-release Tablets
Oral

Initially, 100 mg once daily; increase dosage in 100-mg increments every 5 days, as needed and tolerated, up to 300 mg daily.53

Fixed Combination with Acetaminophen
Oral

75 mg of tramadol hydrochloride every 4–6 hours as needed (up to 300 mg daily).51

Prescribing Limits

Adults

Pain
Conventional Tablets
Oral

Maximum 400 mg daily.1

Extended-release Tablets
Oral

Maximum 300 mg daily.53

Fixed Combination with Acetaminophen
Oral

Maximum 300 mg daily.21 51

Special Populations

Hepatic Impairment

In patients with cirrhosis, 50 mg (as conventional tablets) every 12 hours.1 (See Special Populations under Pharmacokinetics.)

Extended-release tablets not recommended for use in patients with severe (Child-Pugh class C) hepatic impairment.53 Available tablet strengths do not provide sufficient dosing flexibility for safe use in these patients.53

Tramadol in fixed combination with acetaminophen not recommended in patients with hepatic impairment.51

Renal Impairment

Reduced dosage recommended in patients with severe renal impairment (Clcr <30 mL/minute).1 51 (See Special Populations under Pharmacokinetics.)

Severe Renal Impairment

Conventional tablets: 50–100 mg of tramadol every 12 hours (maximum 200 mg daily).1 In hemodialysis patients, administer the patient’s regular dose on dialysis days (not substantially removed by dialysis).1

Fixed combination with acetaminophen: Maximum of 75 mg of tramadol hydrochloride (in combination with acetaminophen) every 12 hours.51

Extended-release tablets not recommended.53 Available tablet strengths do not provide sufficient dosing flexibility for safe use.53

Geriatric Patients

Cautious dosage selection; initiate therapy at the lower end of the dosage range.1 53

In patients >75 years of age, maximum 300 mg daily.1

Cautions for Tramadol Hydrochloride

Contraindications

  • Known hypersensitivity to tramadol, opiate agonists, or any ingredient in the formulation.1 53

  • Acute intoxication with other CNS depressants (e.g., alcohol, sedatives and hypnotics, other centrally acting analgesics, opiate agonists, or psychotropic drugs).1 51 53

Warnings/Precautions

Warnings

Seizures

Seizures reported in patients receiving tramadol at recommended dosages;1 21 38 39 43 44 45 46 53 however, risk is increased with dosages above the recommended range.1 38 39 43 44 46 53

Tramadol increases risk of seizures in patients taking SSRIs, tricyclic antidepressants or other tricyclic compounds (e.g., cyclobenzaprine, promethazine), or other opiate agonists;1 43 44 46 53 may increase the risk in those taking MAO inhibitors, antipsychotic agents, or other drugs that decrease the seizure threshold.1 53

Seizure risk also increased in patients with epilepsy, a history of seizures, or a recognized risk for seizures (e.g., head trauma, metabolic disorders, alcohol and drug withdrawal, CNS infections).1 21 43 46 53

Naloxone administration in patients with tramadol overdose may increase the risk of seizures.1 43 46 53

Suicide

Tramadol-related deaths reported in patients with a history of emotional disturbance, suicidality, or misuse of tranquilizers, alcohol, or other CNS-active drugs.1 51 53

Do not use in patients who are suicidal or addiction prone.1 51 53 Use with caution in patients receiving tranquilizers or antidepressants, those with excessive alcohol consumption, and those with emotional disturbance or depression.1 51 53 Consider nonopiate analgesics in suicidal or depressed patients.1 51

Serotonin Syndrome

Potentially life-threatening serotonin syndrome may occur with tramadol use, particularly with concurrent use of other serotonergic drugs (including serotonin [5-hydroxytryptamine; 5-HT] type 1 receptor agonists [triptans], SSRIs, other SNRIs, tricyclic antidepressants), drugs that impair serotonin metabolism (e.g., MAO inhibitors), or drugs that impair tramadol metabolism (e.g., CYP2D6 and CYP3A4 inhibitors).1 51 53 (See Specific Drugs under Interactions.)

Manifestations may include mental status changes (e.g., agitation, hallucinations, coma), autonomic instability (e.g., tachycardia, labile BP, hyperthermia), neuromuscular aberrations (e.g., hyperreflexia, incoordination), and/or GI symptoms (e.g., nausea, vomiting, diarrhea).1 51 53

Opiate Agonist Precautions

May cause effects similar to those produced by other opiate agonists;1 2 3 4 5 7 8 9 11 53 observe many of the usual precautions of opiate agonist therapy.1 53

Dependence and Abuse

Potential for psychologic and physical dependence of the morphine type (μ-opiate agonist).1 51 52 53 Consider potential abuse when prescribing or dispensing tramadol in situations where increased risk of misuse and abuse may be present.1 51 53

Abuse and misuse of tramadol have been associated with overdose and death; risk of fatal overdose increases with concurrent abuse of alcohol or other CNS depressants.1 51 53

Intentional abuse by crushing or chewing extended-release preparations, “snorting” the powder, or dissolving the contents in water and injecting the solution IV results in uncontrolled delivery of tramadol and the risk of a potentially fatal overdose.53

Monitor all patients receiving opiate agonists for signs of abuse and addiction; however, concerns about abuse and addiction should not prevent the proper management of pain.1 51 53

Physical dependence and tolerance are more likely with prolonged therapy.1 51 53 Abrupt discontinuance may result in symptoms of withdrawal (e.g., anxiety, sweating, insomnia, rigors, pain, nausea, tremors, diarrhea, upper respiratory symptoms, piloerection, and, rarely, hallucinations).1 51 53 Symptoms may be avoided by tapering the dosage when the drug is discontinued.1 51 53

Acute Toxicity

Tramadol taken in excessive doses, either alone or in combination with other CNS depressants (e.g., alcohol), is a cause of drug-related deaths;1 51 53 fatalities associated with both intentional and unintentional overdose.1 21 40 52 53 Concurrent use of alcohol or other CNS depressants increases risk of death.1 51 53

Not recommended in patients who are suicidal or addiction prone.53

Respiratory Depression

Use with caution in patients at risk for respiratory depression.1 51 53

Large doses administered with anesthetic agents or alcohol may cause respiratory depression; treat as overdose.1 51 53 Use naloxone with caution.1 51 53 (See Seizures under Cautions.)

Increased Intracranial Pressure or Head Trauma

Potential for increased carbon dioxide retention and secondary elevation of cerebrospinal fluid pressure in patients with increased intracranial pressure or head trauma; use with caution in such patients.1 51 53

Pupillary changes (miosis) from tramadol may obscure the existence, extent, or course of intracranial pathology.1 51 53

CNS Depression

Performance of activities requiring mental alertness and physical coordination may be impaired.1 51 53

Concurrent use of other CNS depressants may potentiate CNS depression.1 9 11 21 38 51 53 (See Specific Drugs under Interactions.)

Sensitivity Reactions

Serious and fatal anaphylactoid reactions reported, often following the first dose.1 46 51 53 Patients with a history of anaphylactoid reactions to codeine or other opiate agonists may be at increased risk and should not receive tramadol.1 46 53

Pruritus, urticaria, bronchospasm, angioedema, toxic epidermal necrolysis, and Stevens-Johnson syndrome also reported.1 51 53

General Precautions

Acute Abdominal Conditions

Administration may complicate assessment of patients with acute abdominal conditions.1 51 53

Use of Fixed Combinations

When used in fixed combination with acetaminophen, consider the cautions, precautions, and contraindications associated with acetaminophen.51

Because of the potential for hepatotoxicity at higher than recommended dosages, do not use the fixed-combination (tramadol and acetaminophen) preparation concomitantly with other acetaminophen-containing products.51

Specific Populations

Pregnancy

Category C.1 53 Should not be used prior to or during labor unless the potential benefits outweigh the risks.1 53

Lactation

Distributed into milk; use not recommended.1 53

Pediatric Use

Safety and efficacy of tramadol conventional or extended-release tablets not established in children <16 or 18 years of age, respectively.1 53

Tramadol in fixed-combination with acetaminophen not studied in pediatric patients.51

Geriatric Use

Select dosage with caution because of the greater frequency of decreased hepatic, renal, and/or cardiac function and of concomitant disease and drug therapy in geriatric patients.1 51 53 Use with caution, particularly in patients >75 years of age.53

Increased incidence of adverse effects in geriatric patients compared with younger adults.1 53

Clearance reduced in patients >75 years of age;1 51 maximum dose is 300 mg daily.1 (See Special Populations under Pharmacokinetics and also see Geriatric Patients under Dosage and Administration.)

Hepatic Impairment

Metabolism reduced in patients with advanced cirrhosis.1 9 43 53 (See Special Populations under Pharmacokinetics.)

Dosage adjustment may be necessary.1 9 43 53 (See Hepatic Impairment under Dosage and Administration.)

Renal Impairment

Clearance of tramadol and/or active metabolite (M1) may be decreased depending on degree of renal impairment.1 9 43 51 53 (See Special Populations under Pharmacokinetics.)

Dosage adjustment necessary in patients with severe renal impairment.1 (See Renal Impairment under Dosage and Administration.)

Common Adverse Effects

Asthenia, CNS stimulation, constipation, diarrhea, dizziness, dry mouth, dyspepsia, flushing, headache, nausea, pruritus, somnolence, anorexia, sweating, vomiting.1 3 51 53

Interactions for Tramadol Hydrochloride

Metabolized by CYP isoenzymes 2B6, 2D6, and 3A4; formation of active metabolite (M1) dependent on CYP2D6.1 51 53

Drugs Affecting Hepatic Microsomal Enzymes

Inhibitors of CYP2D6: Potential pharmacokinetic interaction (increased plasma tramadol concentrations, decreased plasma M1 concentrations), resulting in increased risk of adverse effects (e.g., seizures, serotonin syndrome).1 51 53 Effect of such changes in tramadol and M1 concentrations on efficacy and safety not fully established.1 51 53

Inhibitors of CYP3A4: Potential pharmacokinetic interaction (decreased tramadol clearance), resulting in increased risk of adverse effects (e.g., seizures, serotonin syndrome).1 51 53

Inducers of CYP3A4: Potential pharmacokinetic interaction (altered plasma tramadol concentrations).1 51 53

Drugs Metabolized by Hepatic Microsomal Enzymes

Unlikely to inhibit CYP3A4-mediated metabolism of other drugs when administered in usual dosages.1 51 53

Specific Drugs

Drug

Interaction

Comments

Anticoagulants, oral

Increased PT and 1 49 53 INR1 48 49 50 53 and extensive ecchymoses reported49

Use with caution;49 closely monitor INR48 49 50

Antidepressants, SSRIs

Increased risk of adverse effects (e.g., serotonin syndrome, seizures)1 51 53

Fluoxetine and paroxetine may inhibit tramadol metabolism, potentially increasing tramadol concentrations, decreasing M1 concentrations, and increasing risk of adverse effects (e.g., seizures, serotonin syndrome)1 51 53

Use with caution;1 51 53 monitor patient closely, particularly during treatment initiation and dosage increases1 47 51 53

Clinical importance of changes in tramadol and M1 concentrations resulting from CYP2D6 inhibitor use not fully established1 51 53

Antidepressants, tricyclics

Increased risk of seizures1 43 44 46 53

Amitriptyline may inhibit tramadol metabolism, potentially increasing tramadol concentrations, decreasing M1 concentrations, and increasing risk of adverse effects (e.g., seizures, serotonin syndrome)1 51 53

Clinical importance of changes in tramadol and M1 concentrations resulting from CYP2D6 inhibitor use not fully established1 51 53

Antifungals, azole (ketoconazole)

Ketoconazole may decrease tramadol clearance, increasing risk of adverse effects (e.g., seizures, serotonin syndrome)1 51 53

Carbamazepine

Decreased analgesic effect due to increased metabolism of tramadol; risk of tramadol-associated seizures1 51 53

Concomitant use not recommended1 51 53

Cimetidine

Tramadol pharmacokinetics not altered1 51 53

CNS depressants (e.g., alcohol, anesthetic agents, phenothiazines, sedatives and hypnotics, other centrally acting analgesics, opiate agonists)

Additive respiratory and CNS depressant effects;1 11 21 38 51 53 increased risk of fatal overdosage1 51 53

Use with caution and in reduced dosage1 9 21 51 53

Digoxin

Digoxin toxicity reported rarely1 51 53

Linezolid

Possible increased risk of serotonin syndrome1 51 53

Use with caution;1 51 53 monitor patient closely, particularly during treatment initiation and dosage increases1 47 51 53

Lithium

Possible increased risk of serotonin syndrome1 51 53

Use with caution;1 51 53 monitor patient closely, particularly during treatment initiation and dosage increases1 47 51 53

Macrolides (erythromycin)

Erythromycin may decrease tramadol clearance, increasing risk of adverse effects (e.g., seizures, serotonin syndrome)1 51 53

MAO inhibitors

Increased risk of adverse effects (e.g., serotonin syndrome, seizures)1 51 53

Use with extreme caution1 51 53

Opiate agonists

Increased risk of seizures1 51 53

(See CNS depressants entry in table)

Quinidine

Quinidine increases tramadol concentrations, decreases M1 concentrations, and may increase risk of adverse effects (e.g., seizures, serotonin syndrome)1 51 53

Clinical importance of altered tramadol and M1 concentrations not fully established1 51 53

Rifampin

Possible altered tramadol metabolism1 51 53

Serotonin receptor agonists (triptans)

Increased risk of adverse effects (e.g., seizures, serotonin syndrome)1 51 53

Use with caution;1 51 53 monitor patient closely, particularly during treatment initiation and dosage increases1 47 51 53

SNRIs

Increased risk of adverse effects (e.g., seizures, serotonin syndrome)1 51 53

Use with caution;1 51 53 monitor patient closely, particularly during treatment initiation and dosage increases1 47 51 53

St. John’s wort (Hypericum perforatum)

Possible altered tramadol metabolism1 51 53

Possible increased risk of serotonin syndrome1 51 53

Use with caution;1 51 53 monitor patient closely, particularly during treatment initiation and dosage increases1 47 51 53

Tramadol Hydrochloride Pharmacokinetics

Absorption

Bioavailability

Rapidly and almost completely absorbed following oral administration; mean absolute bioavailability is approximately 75%.1 Bioavailability of 200-mg extended-release tablet is 85–90% of that of conventional tablets given at equivalent daily dosage (50 mg every 6 hours).53

Peak plasma concentrations of tramadol and its active metabolite, O-desmethyltramadol (M1), usually occur within 2 and 3 hours, respectively, following administration as conventional tablets;1 3 4 11 51 peak concentrations are delayed, occurring within 12 and 15 hours, respectively, following administration as extended-release tablets.53

Onset

Tramadol conventional tablets: Onset of analgesia occurs within 1 hour; peak effects occur within 2–4 hours.1 4 9 15

Duration

Tramadol conventional tablets: Duration of analgesia after a single oral dose is 3–6 hours.4 16

Food

Tramadol conventional tablets: Food does not significantly alter the rate or extent of absorption.1

Tramadol extended-release tablets: High-fat meal decreases peak plasma concentration (by about 28%) and extent of absorption (by about 16%) and delays time to peak plasma concentrations (by approximately 3 hours).53

Fixed combination with acetaminophen: Food delays time to peak plasma tramadol concentration (by approximately 0.5–1 hour).51

Distribution

Extent

Crosses the placenta and is distributed into breast milk.1 53

Plasma Protein Binding

Approximately 20%.1 53

Elimination

Metabolism

Extensively metabolized in the liver; pathways include O-demethylation by CYP2D6 and N-demethylation by CYP3A4 and CYP2B6.1 51 53 Formation of active metabolite (M1) is dependent on CYP2D6.1 51 53

Elimination Route

Excreted in urine as unchanged drug (about 30%) and metabolites (60%).1 51 53

Half-life

Racemic tramadol: mean terminal plasma elimination half-life is approximately 5–6 hours, increasing to 7–9 hours with multiple dosing (conventional tablets);1 51 53 7.9 hours (extended-release tablets).53

Racemic M1: mean terminal plasma elimination half-life is approximately 7 hours (conventional tablets);1 51 53 8.8 hours (extended-release tablets).53

Special Populations

In patients with severe renal impairment, excretion of tramadol and its active metabolite, M1, is reduced.1 51 Extended-release tablets not studied in patients with severe renal impairment.53

In patients with mild to moderate renal impairment receiving multiple doses of tramadol extended-release tablets, systemic exposure to M1 increases with increasing severity of renal impairment; no consistent trend observed for systemic exposure to tramadol.53

In patients with advanced cirrhosis receiving single dose of tramadol conventional tablets, metabolism of tramadol and M1 is reduced; extent of exposure to the drug is increased, and half-lives of tramadol and M1 are prolonged to 13 and 19 hours, respectively.1 Extended-release tablets not studied in patients with severe (Child-Pugh class C) hepatic impairment.53

In patients with mild to moderate (Child-Pugh class A or B) hepatic impairment receiving multiple doses of tramadol extended-release tablets, exposure to tramadol is similar to that in patients with normal hepatic function; however, exposure to M1 decreases with increasing severity of hepatic impairment.53

In geriatric individuals >75 years of age receiving tramadol conventional tablets, peak serum tramadol concentrations are elevated and elimination half-life is prolonged;1 values in individuals 65–75 years of age are comparable to those in younger adults.1

In poor metabolizers (individuals with reduced CYP2D6 activity) receiving tramadol conventional tablets, plasma tramadol concentrations are approximately 20% higher and M1 concentrations are 40% lower than concentrations in extensive (or rapid) metabolizers.1 51

Stability

Storage

Oral

Conventional Tablets

Tight containers at 25°C (may be exposed to 15–30°C).1

Extended-release Tablets

25°C (may be exposed to 15–30°C).53

Actions

  • Acts as an opiate agonist, apparently by selective activity at the μ-receptor.1 2 3 4 5 9 10 11 13 14 16 17 18 19 51 53 Also, inhibits reuptake of norepinephrine and serotonin.1 2 3 4 5 6 8 9 11 16 17 18 19 51 53

  • Can produce dependence, but abuse potential appears to be low;1 2 3 4 5 6 8 9 11 16 17 53 is not subject to control under the Federal Controlled Substances Act of 1970 as a scheduled drug.1 53

Advice to Patients

  • Potential for seizures and/or serotonin syndrome with concomitant use of serotonergic drugs or drugs that substantially decrease the metabolism of tramadol.1 51 53

  • Potential for drug to impair mental alertness or physical coordination; avoid driving or operating machinery until effects on individual are known.1 51 53

  • Importance of women informing their clinician if they are or plan to become pregnant or plan to breastfeed.1 51 53

  • Importance of the single-dose and 24-hour dose limit and the time interval between doses, since exceeding these recommendations can result in respiratory depression, seizures, and death.1 51 53

  • Importance of swallowing extended-release tablets whole; do not crush, chew, or split the tablets.53

  • Importance of informing clinician of existing or contemplated concomitant therapy, including prescription and OTC drugs and alcohol consumption.1 51 53

  • Importance of avoiding alcohol-containing beverages or products.1 51 53

  • Importance of informing patients of other important precautionary information.1 53 (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Tramadol Hydrochloride

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Oral

Tablets, extended-release

100 mg*

Tramadol Hydrochloride Extended-Release Tablets

Ultram ER

PriCara

200 mg*

Tramadol Hydrochloride Extended-Release Tablets

Ultram ER

PriCara

300 mg

Ultram ER

PriCara

Tablets, film-coated

50 mg*

Tramadol Hydrochloride Tablets

Ultram (scored)

PriCara

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Tramadol Hydrochloride Combinations

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Oral

Tablets, film-coated

37.5 mg with Acetaminophen 325 mg*

Tramadol Hydrochloride and Acetaminophen Tablets

Ultracet

PriCara

Comparative Pricing

This pricing information is subject to change at the sole discretion of DS Pharmacy. This pricing information was updated 02/2014. Actual costs to patients will vary depending on the use of specific retail or mail-order locations and health insurance copays.

Ryzolt 200MG 24-hr Tablets (PURDUE PHARMA L.P.): 30/$213.98 or 90/$599.21

TraMADol HCl 100MG 24-hr Tablets (PATRIOT PHARMACEUTICALS LLC): 30/$109.99 or 90/$309.97

TraMADol HCl 200MG 24-hr Tablets (PATRIOT PHARMACEUTICALS LLC): 30/$145.99 or 90/$409.97

TraMADol HCl 50MG Tablets (AMNEAL PHARMACEUTICALS): 30/$16.99 or 90/$47.97

Tramadol-Acetaminophen 37.5-325MG Tablets (MYLAN): 30/$27.99 or 90/$80.97

Ultracet 37.5-325MG Tablets (JANSSEN): 30/$63.99 or 90/$157.97

Ultram 50MG Tablets (JANSSEN): 30/$62.99 or 100/$194.97

Ultram ER 100MG 24-hr Tablets (JANSSEN): 30/$144.99 or 90/$413.95

Ultram ER 200MG 24-hr Tablets (JANSSEN PHARMACEUTICALS): 30/$224.99 or 90/$619.95

Ultram ER 300MG 24-hr Tablets (JANSSEN): 30/$298.00 or 90/$858.00

AHFS DI Essentials. © Copyright, 2004-2014, Selected Revisions February 1, 2011. American Society of Health-System Pharmacists, Inc., 7272 Wisconsin Avenue, Bethesda, Maryland 20814.

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