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Tramadol Hydrochloride

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: Conzip, Ultram, Ultram ER

Medically reviewed on November 13, 2017

Warning

    Addiction, Abuse, and Misuse
  • Risk of addiction, abuse, and misuse, which can lead to overdosage and death.1 53 59 Assess each patient’s risk for addiction, abuse, and misuse before prescribing tramadol; monitor all patients regularly for development of these behaviors or conditions.1 53 59 (See Addiction, Abuse, and Misuse under Cautions.)

    Respiratory Depression
  • Serious, life-threatening, or fatal respiratory depression may occur.1 53 59 Monitor for respiratory depression, especially during initiation of therapy and following dosage increases.1 53 59 (See Respiratory Depression under Cautions.)

  • Patients must swallow extended-release tablets or capsules whole to avoid exposure to a potentially fatal dose.53 59

    Accidental Exposure
  • Accidental ingestion, especially by a child, can result in a fatal overdose.1 53 59

    Neonatal Opiate Withdrawal
  • Prolonged maternal use of opiates during pregnancy can result in neonatal withdrawal syndrome, which may be life-threatening if not recognized and treated.1 53 59 Advise women who require such therapy during pregnancy of this risk and ensure appropriate treatment will be available.1 53 59 (See Pregnancy under Cautions.)

    CYP3A4- and CYP2D6-mediated Interactions
  • Carefully consider the effects of initiation or discontinuance of CYP3A4 inhibitors, CYP3A4 inducers, or CYP2D6 inhibitors on the pharmacokinetics of tramadol and its active metabolite, M1.1 53 59 (See Interactions.)

    Concomitant Use with Benzodiazepines or Other CNS Depressants
  • Concomitant use of opiate agonists with benzodiazepines or other CNS depressants, including alcohol, may result in profound sedation, respiratory depression, coma, and death.1 53 59 416 417 418 700 701 702 703

  • Reserve concomitant use of opiate analgesics and benzodiazepines or other CNS depressants for patients in whom alternative treatment options are inadequate; use lowest effective dosages and shortest possible duration of concomitant therapy and monitor closely for respiratory depression and sedation.1 53 59 700 703 (See Specific Drugs under Interactions.)

Introduction

See also: Lyrica

Synthetic opiate agonist and inhibitor of norepinephrine and serotonin uptake;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

Conventional tablets: Management of pain that is severe enough to require an opiate analgesic1 2 3 4 6 7 10 11 16 and for which alternative treatment options (e.g., nonopiate analgesics) have not been, or are not expected to be, adequate or tolerated.1 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

Extended-release tablets or capsules: Management of pain that is severe enough to require long-term, daily, around-the-clock use of an opiate analgesic and for which alternative treatment options (e.g., nonopiate analgesics, immediate-release opiates) are inadequate or not tolerated; not indicated for as-needed (“prn”) use.53 59 Efficacy established in 2 studies in patients with moderate to moderately severe chronic pain associated with osteoarthritis; several other studies failed to provide adequate evidence of efficacy.53 54 59

Tramadol/acetaminophen tablets: Short-term (≤5 days) management of acute pain that is severe enough to require an opiate analgesic and for which alternative treatment options (e.g., nonopiate analgesics) have not been, or are not expected to be, adequate or tolerated.51

American College of Rheumatology (ACR) states tramadol can be considered in patients with osteoarthritis in whom NSAIAs are contraindicated (e.g., those with renal impairment) or in whom acetaminophen or NSAIAs have not produced an adequate response.55

In symptomatic treatment of acute pain, reserve opiate analgesics for pain resulting from severe injuries, severe medical conditions, or surgical procedures, or when nonopiate alternatives for relieving pain and restoring function are expected to be ineffective or are contraindicated.431 432 433 435 Use smallest effective dosage for shortest possible duration since long-term opiate use often begins with treatment of acute pain.411 431 434 435 Optimize concomitant use of other appropriate therapies.432 434 435 (See Managing Opiate Therapy for Acute Pain under Dosage and Administration.)

Generally use opiates for management of chronic pain (i.e., pain lasting >3 months or past the time of normal tissue healing410 411 412 413 ) that is not associated with active cancer treatment, palliative care, or end-of-life care only if other appropriate nonpharmacologic and nonopiate pharmacologic strategies have been ineffective and expected benefits for both pain relief and functional improvement are anticipated to outweigh risks.411 412 413 414 422 429

If used for chronic pain, opiate analgesics should be part of an integrated approach that also includes appropriate nonpharmacologic modalities (e.g., cognitive-behavioral therapy, relaxation techniques, biofeedback, functional restoration, exercise therapy, certain interventional procedures) and other appropriate pharmacologic therapies (e.g., nonopiate analgesics, analgesic adjuncts such as selected anticonvulsants and antidepressants for certain neuropathic pain conditions).411 412 413 422 429

Available evidence insufficient to determine whether long-term opiate therapy for chronic pain results in sustained pain relief or improvements in function and quality of life411 423 431 432 436 or is superior to other pharmacologic or nonpharmacologic treatments.432 Use is associated with serious risks (e.g., opiate use disorder, overdose).411 431 436 (See Managing Opiate Therapy for Chronic Noncancer Pain under Dosage and Administration.)

Tramadol Hydrochloride Dosage and Administration

General

Managing Opiate Therapy for Acute Pain

  • Optimize concomitant use of other appropriate therapies.432 434 435

  • When opiate analgesia required, use conventional (immediate-release) opiates in smallest effective dosage and for shortest possible duration, since long-term opiate use often begins with treatment of acute pain.411 431 434 435

  • When sufficient for pain management, use lower-potency opiate analgesics given in conjunction with acetaminophen or an NSAIA on as-needed (“prn”) basis.432

  • For acute pain not related to trauma or surgery, limit prescribed quantity to amount needed for expected duration of pain severe enough to require opiate analgesia (generally ≤3 days and rarely >7 days).411 433 434 435 Do not prescribe larger quantities for use in case pain continues longer than expected;411 432 instead, reevaluate patient if severe acute pain does not remit.411 431 435

  • For moderate to severe postoperative pain, provide opiate analgesic as part of a multimodal regimen that also includes acetaminophen and/or NSAIAs and other pharmacologic (e.g., certain anticonvulsants, regional local anesthetic techniques) and nonpharmacologic therapy as appropriate.430 431 432

  • Oral administration of conventional opiate analgesics generally preferred over IV administration in postoperative patients who can tolerate oral therapy.430 431

  • Scheduled (around-the-clock) dosing frequently is required during immediate postoperative period or following major surgery.430 432 When repeated parenteral administration is required, IV patient-controlled analgesia (PCA) generally is recommended.430 431

Managing Opiate Therapy for Chronic Noncancer Pain

  • Although specific recommendations may vary, common elements in clinical guideline recommendations include risk mitigation strategies, upper dosage thresholds, careful dosage titration, and consideration of risks associated with particular opiates and formulations, coexisting diseases, and concomitant drug therapy.410 411 414 415 423

  • Prior to initiating therapy, thoroughly evaluate patient; assess risk factors for misuse, abuse, and addiction;411 412 413 415 422 429 establish treatment goals (including realistic goals for pain and function); and consider how therapy will be discontinued if benefits do not outweigh risks.411 415

  • Regard initial opiate therapy for chronic noncancer pain as a therapeutic trial that will be continued only if there are clinically meaningful improvements in pain and function that outweigh treatment risks.411 412 413

  • Prior to and periodically during therapy, discuss with patients known risks and realistic benefits and patient and clinician responsibilities for managing therapy.411 412 413 414 415

  • Some experts recommend initiating opiate therapy for chronic noncancer pain with conventional (immediate-release) opiate analgesics prescribed at lowest effective dosage.411 415 Individualize opiate selection, initial dosage, and dosage titration based on patient’s health status, prior opiate use, attainment of therapeutic goals, and predicted or observed harms.412 413

  • Evaluate benefits and harms within 1–4 weeks following initiation of therapy or dosage increase411 413 and reevaluate on ongoing basis (e.g., at least every 3 months411 ) throughout therapy.411 412 413 Document pain intensity and level of functioning and assess progress toward therapeutic goals, presence of adverse effects, and adherence to prescribed therapies.412 413 422 423 Anticipate and manage common adverse effects (e.g., constipation, nausea and vomiting, cognitive and psychomotor impairment).412 413 415 If benefits do not outweigh harms, optimize other therapies and taper opiate to lower dosage or taper and discontinue opiate.411 412 413 415

  • When repeated dosage increases required, evaluate potential causes and reassess relative benefits and risks.412 413 Although evidence is limited, some experts state that opiate rotation may be considered in patients with intolerable adverse effects or inadequate benefit despite dosage increases.412 413 415

  • Higher dosages require particular caution,410 412 415 including more frequent and intensive monitoring or referral to specialist.411 412 413 Greater benefits of high-dose opiates for chronic pain not established in controlled clinical studies; higher dosages associated with increased risks (motor vehicle accidents, overdosage, opiate use disorder).411 415 423 424 425 426

  • CDC states that primary care clinicians should carefully reassess individual benefits and risks before prescribing dosages equivalent to ≥50 mg of morphine sulfate daily for chronic pain and should avoid dosages equivalent to ≥90 mg of morphine sulfate daily or carefully justify decision to prescribe such dosages.411 Other experts recommend consulting a pain management specialist before exceeding a dosage equivalent to 80–120 mg of morphine sulfate daily.423 431 Some states have established opiate dosage thresholds (e.g., maximum daily dosages that can be prescribed, dosage thresholds at which consultation with specialist is mandated or recommended)411 420 421 423 or have mandated risk-management strategies (e.g., review of state prescription drug monitoring program [PDMP] data prior to prescribing).411 419 423

  • Recommended strategies for managing risks include written treatment agreements or plans (e.g., “contracts”), urine drug testing, review of state PDMP data, and risk assessment and monitoring tools.410 411 412 413 414 415 422 423 429

  • Taper and discontinue opiate therapy if patient engages in serious or repeated aberrant drug-related behaviors or drug abuse or diversion.412 413 415 Offer or arrange treatment for patients with opiate use disorder.411 412 413

  • Consider providing concomitant naloxone for patients at increased risk of opiate overdosage (e.g., those with history of overdose or substance use disorder, those receiving ≥50 mg of morphine sulfate [or equivalent] daily, those receiving benzodiazepines concomitantly, those with medical conditions that could increase sensitivity to opiate effects).411 431

Administration

Oral Administration

Administer orally alone or in fixed combination with acetaminophen.1 51 53 59

Do not use extended-release tramadol preparations concomitantly with other tramadol-containing preparations.53 59

Conventional Tablets

Administer without regard to meals.1

Extended-release Tablets

Administer once daily without regard to food, but in a consistent manner relative to food intake.53

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

Extended-release Capsules

Administer once daily without regard to food, but in a consistent manner relative to food intake.59

Swallow capsules whole with liquid; do not break, chew, split, or dissolve.59

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 59

Use lowest effective dosage and shortest duration of therapy consistent with treatment goals of the patient.1 53 59 411 413 431 432 435

Individualize initial dosage based on severity of pain, response, prior analgesic use, and risk factors for addiction, abuse, and misuse.1 53 59

When switching patients receiving chronic opiate therapy from one opiate analgesic to another, generally reduce the calculated equianalgesic dosage of the new opiate agonist by about 25–50% to avoid inadvertent overdosage.410 412 This calculation does not apply when switching to methadone; consult specific recommendations for methadone dosage.412

When used concomitantly with other CNS depressants, use lowest effective dosages and shortest possible duration of concomitant therapy.1 53 59 700 703 (See Specific Drugs under Interactions.)

Appropriate dosage selection and titration are essential to reduce the risk of respiratory depression.1 53 59 Monitor closely for respiratory depression, especially during the first 24–72 hours of therapy and following any increase in dosage.1 53 59

Frequent communication among the prescriber, other members of the healthcare team, the patient, and the patient's caregiver or family is important during periods of changing analgesic requirements, including the initial dosage titration period.1 53 59

Titrate dosage to a level that provides adequate analgesia and minimizes adverse effects.1 53 59 If level of pain increases after dosage stabilization, attempt to identify source of increased pain before increasing dosage.1 53 59

Continually assess adequacy of pain control and reevaluate for adverse effects, as well as for development of addiction, abuse, or misuse.1 53 59 During long-term therapy, continually reevaluate continued need for opiate analgesics.53 59

Patients with chronic pain who experience episodes of breakthrough pain may require dosage adjustment or supplemental analgesia (i.e., “rescue” therapy with an immediate-release analgesic).53 59

When discontinuing tramadol in a patient who may be physically dependent on opiates, generally reduce dosage by 25–50% every 2–4 days.1 53 59 If manifestations of withdrawal occur, increase dosage to the prior level and taper more slowly (increase interval between dosage reductions and/or reduce amount of each incremental change in dose).1 53 59

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 and Capsules
Oral

Patients not currently receiving tramadol (including those being switched from other opiate analgesics): Initially, 100 mg once daily; increase dosage in 100-mg increments every 5 days, as needed and tolerated, up to 300 mg daily.53 59 Ratios for conversion from other opiate analgesics to extended-release tramadol preparations not established in clinical trials.53 59

Patients currently receiving immediate-release tramadol: Calculate total daily dosage of the immediate-release drug and round down to the next lower 100-mg increment; make subsequent dosage adjustments based on patient requirements.53 59 Monitor closely for sedation and respiratory depression (data on relative bioavailability of immediate-release and extended-release preparations are lacking).1

Because of limitations in dose selection, some patients may not be successfully switched from immediate-release to extended-release tramadol preparations.53 59

Discontinue all other around-the-clock opiate analgesics when therapy with extended-release tramadol is initiated.53 59

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
Oral

For acute pain not related to trauma or surgery, limit prescribed quantity to amount needed for the expected duration of pain severe enough to require opiate analgesia (generally ≤3 days and rarely >7 days).411 433 434 435

CDC recommends that primary care clinicians carefully reassess individual benefits and risks before prescribing dosages equivalent to ≥50 mg of morphine sulfate daily for chronic pain and avoid dosages equivalent to ≥90 mg of morphine sulfate daily or carefully justify their decision to prescribe such dosages.411 Other experts recommend consulting a pain management specialist before exceeding a dosage equivalent to 80–120 mg of morphine sulfate daily.423 431

Some states have set prescribing limits (e.g., maximum daily dosages that can be prescribed, dosage thresholds at which consultation with a specialist is mandated or recommended).411 420 421 423

Conventional Tablets
Oral

Maximum 400 mg daily.1

Extended-release Tablets or Capsules
Oral

Maximum 300 mg daily.53 59

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 oral formulations not recommended for use in patients with severe (Child-Pugh class C) hepatic impairment.53 59 Available tablet or capsule strengths and once-daily dosing do not provide sufficient dosing flexibility for safe use in these patients.53 59

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 oral formulations not recommended.53 59 Available tablet or capsule strengths and once-daily dosing do not provide sufficient dosing flexibility for safe use.53 59

Geriatric Patients

Cautious dosage selection;1 53 59 initiate therapy at the lower end of the dosage range.1

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

Titrate dosage slowly with close monitoring for CNS and respiratory depression.51 53 59 (See Geriatric Use under Cautions.)

Cautions for Tramadol Hydrochloride

Contraindications

  • Known hypersensitivity (e.g., anaphylaxis) to tramadol, opiate agonists, or any ingredient in the formulation.1 53 59

  • Substantial respiratory depression.1 53 59

  • Acute or severe bronchial asthma in unmonitored settings or in the absence of resuscitative equipment.1 53 59

  • Known or suspected GI obstruction, including paralytic ileus.1 53 59

  • Current or recent (within 14 days) therapy with an MAO inhibitor.1 53 59

  • In children <12 years of age for the management of pain.705

  • In children <18 years of age for the management of postoperative pain following tonsillectomy and/or adenoidectomy.705 (See Pediatric Use under Cautions.)

Warnings/Precautions

Warnings

Addiction, Abuse, and Misuse

Risk of addiction, abuse, and misuse.1 53 59 Addiction can occur with appropriately prescribed or illicitly obtained opiates, and at recommended dosages or with misuse or abuse.1 53 59 Abuse of tramadol can result in overdosage and death; concurrent abuse of alcohol or other CNS depressants increases risk of toxicity.1 53 59 Abuse potential is less than that of morphine or oxycodone but similar to that of propoxyphene (see Actions).56

Assess each patient’s risk for addiction, abuse, and misuse prior to prescribing; monitor all patients for development of these behaviors or conditions.1 53 59 Personal or family history of substance abuse (drug or alcohol addiction or abuse) or mental illness (e.g., major depression) increases risk.1 53 59 The potential for addiction, abuse, and misuse should not prevent opiate prescribing for appropriate pain management, but does necessitate intensive counseling about risks and proper use and intensive monitoring for signs of addiction, abuse, and misuse.1 53 59

Extended-release formulations are associated with a greater risk of overdosage and death because of the larger amount of drug contained in each dosage unit.53 59

Abuse or misuse of extended-release formulations by splitting, crushing, breaking, cutting, or chewing the tablets or capsules, snorting the contents, or injecting the dissolved contents will result in uncontrolled delivery of tramadol and can result in fatal overdosage.53 59 IV injection of excipients in these formulations can result in local tissue necrosis, infection, pulmonary granulomas, embolism, and death and increase the risk of endocarditis and valvular heart injury.53 59

Prescribe in smallest appropriate quantity and instruct patients on secure storage and proper disposal to prevent theft.1 53 59

Respiratory Depression

Serious, life-threatening, or fatal respiratory depression can occur with use of opiates, even when used as recommended; can occur at any time during therapy, but risk is greatest during initiation of therapy and following dosage increases.1 53 59 Monitor for respiratory depression, especially during first 24–72 hours of therapy and following any dosage increase.1 53 59

Carbon dioxide retention from opiate-induced respiratory depression can exacerbate the drug's sedative effects and, in certain patients, can lead to elevated intracranial pressure.1 53 59 (See Increased Intracranial Pressure or Head Trauma under Cautions.)

Geriatric, cachectic, or debilitated patients are at increased risk for life-threatening respiratory depression.1 53 59 Closely monitor such patients, particularly following initiation of therapy, during dosage titration, and during concomitant therapy with other respiratory depressants.1 53 59 Consider use of nonopiate analgesics.1 53 59

Even recommended doses of tramadol may decrease respiratory drive to the point of apnea in patients with COPD or cor pulmonale, substantially decreased respiratory reserve, hypoxia, hypercapnia, or preexisting respiratory depression.1 53 59 Closely monitor such patients, particularly following initiation of therapy, during dosage titration, and during concomitant therapy with other respiratory depressants.1 53 59 Consider use of nonopiate analgesics.1 53 59

Appropriate dosage selection and titration are essential to reduce the risk of respiratory depression.1 53 59 Overestimation of the dosage when transferring patients from another opiate analgesic can result in fatal overdosage with the first dose; large initial doses in nontolerant patients also can result in fatal overdosage.1 53 59

Accidental ingestion of even 1 dose, especially by a child, can result in respiratory depression and fatal overdosage.1 53 59

For clinically important respiratory depression resulting from tramadol overdosage, administer an opiate antagonist.1 53 59 (See Seizures under Cautions.)

Consider offering naloxone when opiate agonists are prescribed for patients at increased risk of opiate overdosage (e.g., those with history of overdose or substance use disorder, those receiving ≥50 mg of morphine sulfate [or equivalent] daily, those receiving benzodiazepines concomitantly, those with medical conditions that could increase sensitivity to opiates).411 431

Interactions with Drugs Affecting Hepatic Microsomal Enzymes

Effects of concomitant use or discontinuance of CYP3A4 inducers, CYP3A4 inhibitors, or CYP2D6 inhibitors on concentrations of tramadol and active metabolite M1 are complex and must be carefully considered.1 53 59 (See Interactions.)

Concomitant Use with Benzodiazepines or Other CNS Depressants

Concomitant use of opiates, including tramadol, and benzodiazepines or other CNS depressants (e.g., anxiolytics, sedatives, hypnotics, tranquilizers, muscle relaxants, general anesthetics, antipsychotics, other opiate agonists, alcohol) may result in profound sedation, respiratory depression, coma, and death.1 53 59 416 417 418 700 701 702 703 Substantial proportion of fatal opiate overdoses involve concurrent benzodiazepine use.416 417 418 435 700 701

Reserve concomitant use of tramadol and other CNS depressants for patients in whom alternative treatment options are inadequate.1 53 59 700 703 (See Specific Drugs under Interactions.)

Sensitivity Reactions

Serious and fatal anaphylactoid reactions reported, often following the first dose.1 46 53 59 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 59 If anaphylaxis or other hypersensitivity reaction occurs, discontinue tramadol immediately and permanently.1 53 59

Pruritus, urticaria, bronchospasm, angioedema, toxic epidermal necrolysis, and Stevens-Johnson syndrome also reported.1 53 59

Other Warnings and Precautions

Only clinicians who are knowledgeable in the use of potent opiates for the management of chronic pain should prescribe extended-release tramadol preparations.53 59

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 usual precautions of opiate agonist therapy.1 53 59

Serotonin Syndrome

Potentially life-threatening serotonin syndrome may occur with tramadol use, particularly with concurrent use of other serotonergic drugs,1 53 59 400 drugs that impair serotonin metabolism (e.g., MAO inhibitors),1 53 59 400 or drugs that impair tramadol metabolism (e.g., CYP2D6 and CYP3A4 inhibitors).1 53 59 (See 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, rigidity), and/or GI symptoms (e.g., nausea, vomiting, diarrhea).1 53 59 400

Seizures

Seizures reported in patients receiving tramadol at recommended dosages;1 21 38 39 43 44 45 46 53 59 however, risk is increased with dosages above the recommended range.1 38 39 43 44 46 53 59

Tramadol increases risk of seizures in patients taking SSRIs, SNRIs, anorectic agents, tricyclic antidepressants or other tricyclic compounds (e.g., cyclobenzaprine, promethazine), or other opiate agonists;1 43 44 46 53 59 may increase the risk in those taking MAO inhibitors, antipsychotic agents, or other drugs that decrease the seizure threshold.1 53 59

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 59

Naloxone administration in patients with tramadol overdose may increase the risk of seizures.1 43 46 53 59

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 53 59

Do not use in patients who are suicidal or addiction prone.1 53 59 Use with caution in patients with history of misuse, patients receiving CNS-active drugs (e.g., tranquilizers, antidepressants), those with excessive alcohol consumption, and those with emotional disturbance or depression.1 53 59 Consider nonopiate analgesics in suicidal or depressed patients.1 53 59

Pharmacogenomics

Individuals who carry the genotype associated with ultrarapid metabolism of CYP2D6 substrates (e.g., approximately 1–7% of Caucasians, 10–30% of Ethiopians and Saudi Arabians) convert tramadol to the active metabolite, O-desmethyltramadol (M1), more rapidly and completely than other individuals.60 107 108 110 112 114 705 (See Pharmacokinetics.)

Because individuals who are ultrarapid metabolizers of CYP2D6 substrates are likely to have higher than expected serum concentrations of M1, FDA states that tramadol should not be used in such patients.705

Adrenal Insufficiency

Adrenal insufficiency reported in patients receiving opiate agonists or opiate partial agonists.1 53 59 400 Manifestations are nonspecific and may include nausea, vomiting, anorexia, fatigue, weakness, dizziness, and hypotension.1 53 59 400

If adrenal insufficiency is suspected, perform appropriate laboratory testing promptly and provide physiologic (replacement) dosages of corticosteroids; taper and discontinue the opiate agonist or partial agonist to allow recovery of adrenal function.1 53 59 400 If the opiate agonist or partial agonist can be discontinued, perform follow-up assessment of adrenal function to determine if corticosteroid replacement therapy can be discontinued.400 In some patients, switching to a different opiate improved symptoms.1 53 59 400

Hypotension

May cause severe hypotension, including orthostatic hypotension and syncope, in ambulatory patients, especially in individuals whose ability to maintain their BP is compromised by depleted blood volume or concomitant use of certain CNS depressants (e.g., phenothiazines, general anesthetics).1 53 59 Monitor BP following initiation of therapy and dosage increases in such patients.1 53 59 (See Specific Drugs under Interactions.)

Vasodilation produced by the drug may further reduce cardiac output and BP in patients with circulatory shock.1 53 59 Avoid use in such patients.1 53 59

Increased Intracranial Pressure or Head Trauma

Potential for increased carbon dioxide retention and secondary elevation of intracranial pressure; in patients particularly susceptible to these effects (e.g., those with evidence of elevated intracranial pressure or brain tumors), monitor closely for sedation and respiratory depression, particularly during initiation of therapy.1 53 59

Opiates may obscure the clinical course in patients with head injuries.1 53 59

Avoid use in patients with impaired consciousness or coma.1 53 59

GI Conditions

May cause spasm of the sphincter of Oddi and increase serum amylase concentrations; monitor patients with biliary disease, including acute pancreatitis, for worsening symptoms.1 53 59

Contraindicated in patients with known or suspected GI obstruction, including paralytic ileus.1 53 59

Dependence and Tolerance

Physical dependence and tolerance can develop during prolonged therapy.1 53 59 Abrupt discontinuance or substantial dosage reduction may result in symptoms of withdrawal (e.g., restlessness, lacrimation, rhinorrhea, yawning, sweating, chills, myalgia, mydriasis, irritability, anxiety, backache, joint pain, weakness, abdominal cramps, insomnia, nausea, anorexia, vomiting, diarrhea, increased BP, respiratory rate, or heart rate).1 53 59 Symptoms may be avoided by tapering the dosage when the drug is discontinued.1 53 59

Avoid concomitant use of opiate partial agonists.1 53 59 (See Specific Drugs under Interactions.)

Infants born to women who are physically dependent on opiates also will be physically dependent.1 53 59 (See Pregnancy under Cautions.)

CNS Depression

Performance of activities requiring mental alertness and physical coordination may be impaired.1 53 59

Concurrent use with other CNS depressants may potentiate CNS depression1 9 11 21 38 53 59 and may result in profound sedation, respiratory depression, coma, or death.1 53 59 700 703 (See Concomitant Use with Benzodiazepines or Other CNS Depressants under Cautions.)

Hypogonadism

Hypogonadism or androgen deficiency reported in patients receiving long-term opiate agonist or opiate partial agonist therapy;1 53 59 400 401 402 403 404 causality not established.1 53 59 400 Manifestations may include decreased libido, impotence, erectile dysfunction, amenorrhea, or infertility.1 53 59 400 Perform appropriate laboratory testing in patients with manifestations of hypogonadism.400

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

Analysis of data from the National Birth Defects Prevention Study (large population-based, case-control study) suggests therapeutic use of opiates in pregnant women during organogenesis is associated with a low absolute risk of birth defects, including heart defects, spina bifida, and gastroschisis.61 62 Manufacturers state that data for tramadol are insufficient to establish risk of major birth defects and spontaneous abortion.1 53 59

In animal studies, tramadol was embryotoxic and fetotoxic; teratogenicity not observed.1 53 59 Based on animal data, apprise patient of potential fetal risk.1 53 59

Use of opiates in pregnant women during labor can result in neonatal respiratory depression.1 53 59 Use of tramadol immediately before or during labor is not recommended.1 53 59 Monitor neonates exposed to opiates during labor for respiratory depression and excessive sedation; an opiate antagonist must be available for reversal of opiate-induced respiratory depression.1 53 59

Prolonged maternal use of opiates during pregnancy can result in neonatal opiate withdrawal syndrome; in contrast to adults, withdrawal syndrome in neonates may be life-threatening and requires management according to protocols developed by neonatology experts.1 53 59 Syndrome presents with irritability, hyperactivity and abnormal sleep pattern, high-pitched cry, tremor, vomiting, diarrhea, and failure to gain weight.1 53 59 Onset, duration, and severity vary depending on the specific opiate used, duration of use, timing and amount of last maternal use, and rate of drug elimination by the neonate.1 53 59

Lactation

Distributed into milk; use not recommended.1 53 59 705 Risk of opiate toxicity in nursing infants,1 53 59 705 especially if the mother is an ultrarapid metabolizer of tramadol.705 (See Pharmacogenomics under Cautions.)

Closely monitor infants exposed to tramadol through breast milk for manifestations of opiate toxicity (e.g., sedation, difficulty breast-feeding or breathing, hypotonia);1 53 59 if such manifestations occur, caregiver should seek immediate medical treatment for the infant.705

Symptoms of withdrawal can occur in opiate-dependent infants when maternal administration of opiates is discontinued or breast-feeding is stopped.1 53 59

Pediatric Use

Safety and efficacy of tramadol not established in pediatric patients.1 51 53 59

Use contraindicated in children <12 years of age; also contraindicated in children <18 years of age following tonsillectomy and/or adenoidectomy.705 FDA states that tramadol is not recommended in children 12–18 years of age who are obese or have conditions such as obstructive sleep apnea or compromised respiratory function.705

Respiratory depression, including deaths, reported in children <18 years of age; children who are obese, have obstructive sleep apnea or severe lung disease, or have evidence of ultrarapid metabolism of CYP2D6 substrates are at increased risk.705 If tramadol is used in children 12–18 years of age, caregivers should monitor closely for manifestations of opiate toxicity and seek immediate medical treatment for the child if such manifestations occur.57 705

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.51 Use with caution, particularly in patients >75 years of age.53 59

Increased incidence of adverse effects in geriatric patients compared with younger adults.1 53 59

Respiratory depression is the chief risk; monitor closely for CNS and respiratory depression.1 53 59

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

May be useful to monitor renal function; tramadol clearance may be decreased and risk of adverse effects increased in patients with impaired renal function.1 53 59

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 (See Hepatic Impairment under Dosage and Administration.)

Renal Impairment

Clearance of tramadol and/or active M1 metabolite 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 59

Interactions for Tramadol Hydrochloride

Metabolized by CYP isoenzymes 2B6, 2D6, and 3A4; formation of M1 dependent on CYP2D6.1 51 53 59

Drugs Affecting Hepatic Microsomal Enzymes

Inhibitors of CYP2D6: Potential pharmacokinetic interaction (increased plasma tramadol concentrations, decreased plasma M1 concentrations).1 53 59 Increased tramadol concentrations may increase or prolong therapeutic effects and increase risk of adverse effects (e.g., seizures, serotonin syndrome); decreased M1 concentrations may reduce therapeutic effects and precipitate withdrawal.1 53 59 If concomitant therapy required, monitor closely for serious adverse effects (e.g., seizures, serotonin syndrome) and opiate toxicity or withdrawal.1 53 59 If CYP2D6 inhibitor is discontinued, monitor closely for adverse effects (e.g, respiratory depression, sedation) and consider reducing tramadol dosage until drug effects are stable.1 53 59

Inhibitors of CYP3A4: Potential pharmacokinetic interaction (increased plasma tramadol concentrations; larger amounts of parent drug available for metabolism may result in higher M1 concentrations).1 53 59 If concomitant therapy required, monitor closely for serious adverse effects (e.g., seizures, serotonin syndrome) and opiate toxicity, and consider decreasing tramadol dosage until drug effects are stable.1 53 59 If CYP3A4 inhibitor is discontinued, monitor for opiate withdrawal and consider increasing tramadol dosage until drug effects are stable.1 53 59

Inducers of CYP3A4: Potential pharmacokinetic interaction (decreased plasma tramadol concentrations); may reduce efficacy or precipitate opiate withdrawal.1 53 59 If concomitant therapy required, monitor for opiate withdrawal and consider increasing tramadol dosage until stable drug effects are achieved.1 53 59 If CYP3A4 inducer is discontinued, monitor for seizures, serotonin syndrome, sedation, and respiratory depression, and consider decreasing tramadol dosage until drug effects are stable.1 53 59

Drugs Metabolized by Hepatic Microsomal Enzymes

Unlikely to inhibit CYP3A4-mediated metabolism of other drugs when administered in usual dosages.1 53 59

Drugs Associated with Serotonin Syndrome

Risk of serotonin syndrome when used with other serotonergic drugs.1 47 53 59 400 May occur at usual dosages.1 53 59 400 Symptom onset generally occurs within several hours to a few days of concomitant use, but may occur later, particularly after dosage increases.1 53 59 400 (See Advice to Patients.)

If concomitant use of other serotonergic drugs is warranted, monitor patients for serotonin syndrome, particularly during initiation of therapy and dosage increases.1 47 53 59 400

If serotonin syndrome is suspected, discontinue tramadol,1 53 59 other opiate therapy, and/or any concurrently administered serotonergic agents.400

Specific Drugs

Drug

Interaction

Comments

Amiodarone

May inhibit tramadol metabolism, increasing tramadol concentrations and decreasing M1 concentrations; increased tramadol concentrations may increase or prolong therapeutic effects and increase risk of adverse effects (e.g., seizures, serotonin syndrome); decreased M1 concentrations may reduce therapeutic effects and precipitate withdrawal1 53 59

Monitor closely for serious adverse effects (e.g., seizures, serotonin syndrome) and opiate toxicity or withdrawal; if amiodarone is discontinued, monitor closely for adverse effects (e.g., respiratory depression, sedation) and consider reducing tramadol dosage until drug effects are stable1 53 59

Anorectic agents

Increased risk of seizures1 53 59

Anticholinergic agents

Possible increased risk of urinary retention and/or severe constipation, which may lead to paralytic ileus1 53 59

Monitor for urinary retention or reduced gastric motility1 53 59

Anticonvulsants (carbamazepine, phenytoin)

May increase tramadol metabolism, decreasing tramadol concentrations and reducing efficacy or precipitating opiate withdrawal1 53 59

Carbamazepine: Analgesia is substantially reduced1 53 59

Phenytoin: Monitor for opiate withdrawal and consider increasing tramadol dosage until drug effects are stable; if phenytoin is discontinued, monitor for seizures, serotonin syndrome, sedation, and respiratory depression, and consider decreasing tramadol dosage until drug effects are stable1 53 59

Carbamazepine: Concomitant use not recommended1 53 59

Antidepressants, SSRIs (e.g., citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline), SNRIs (e.g., desvenlafaxine, duloxetine, milnacipran, venlafaxine), tricyclic antidepressants (TCAs), mirtazapine, nefazodone, trazodone, vilazodone

Increased risk of serotonin syndrome1 53 59 400

SSRIs, SNRIs, TCAs: Increased risk of seizures1 43 44 46 53 59

Amitriptyline, fluoxetine, paroxetine: May inhibit tramadol metabolism, increasing tramadol concentrations and decreasing M1 concentrations; increased tramadol concentrations may increase or prolong therapeutic effects and increase risk of adverse effects (e.g., seizures, serotonin syndrome); decreased M1 concentrations may reduce therapeutic effects and precipitate withdrawal1 53 59

If concomitant use warranted, monitor patient closely, particularly during treatment initiation and dosage increases1 47 51 53 59 400

If serotonin syndrome suspected, discontinue tramadol,1 53 59 the antidepressant, and/or any concurrently administered opiates or serotonergic agents400

Amitriptyline, fluoxetine, paroxetine: Monitor closely for serious adverse effects (e.g., seizures, serotonin syndrome) and opiate toxicity or withdrawal; if antidepressant is discontinued, monitor closely for adverse effects (e.g., respiratory depression, sedation) and consider reducing tramadol dosage until drug effects are stable1 53 59

Antiemetics, 5-HT3 receptor antagonists (e.g., dolasetron, granisetron, ondansetron, palonosetron)

Risk of serotonin syndrome1 53 59 400

If concomitant use warranted, monitor for serotonin syndrome, particularly during initiation of therapy and dosage increases1 53 59 400

If serotonin syndrome suspected, discontinue tramadol,1 53 59 the 5-HT3 receptor antagonist, and/or any concurrently administered opiates or serotonergic agents400

Antifungals, azole (ketoconazole)

May decrease tramadol clearance; increased tramadol concentrations may increase M1 formation; increased risk of adverse effects (e.g., seizures, serotonin syndrome) and opiate toxicity1 53 59

Monitor closely for serious adverse effects (e.g., seizures, serotonin syndrome) and opiate toxicity, and consider reducing tramadol dosage until drug effects are stable; if antifungal is discontinued, monitor for opiate withdrawal and consider increasing tramadol dosage until drug effects are stable1 53 59

Antipsychotics (e.g., aripiprazole, asenapine, cariprazine, chlorpromazine, clozapine, fluphenazine, haloperidol, iloperidone, loxapine, lurasidone, molindone, olanzapine, paliperidone, perphenazine, pimavanserin, quetiapine, risperidone, thioridazine, thiothixene, trifluoperazine, ziprasidone)

Risk of profound sedation, respiratory depression, hypotension, coma, or death1 53 59 700 703

Use concomitantly only if alternative treatment options are inadequate; use lowest effective dosages and shortest possible duration of concomitant therapy1 53 59 700 703

In patients receiving tramadol, initiate antipsychotic, if required, at lower dosage than indicated in the absence of opiate therapy and titrate based on clinical response1 53 59 700 703

In patients receiving an antipsychotic, initiate tramadol, if required, at reduced dosage and titrate based on clinical response1 53 59 700 703

Monitor closely for respiratory depression and sedation1 53 59 700 703

Benzodiazepines (e.g., alprazolam, chlordiazepoxide, clobazam, clonazepam, clorazepate, diazepam, estazolam, flurazepam, lorazepam, midazolam, oxazepam, quazepam, temazepam, triazolam)

Risk of profound sedation, respiratory depression, hypotension, coma, or death1 53 59 416 417 418 700 701 703

Whenever possible, avoid concomitant use410 411 415 435

Use concomitantly only if alternative treatment options are inadequate; use lowest effective dosages and shortest possible duration of concomitant therapy1 53 59 700 703

In patients receiving tramadol, initiate benzodiazepine, if required for any indication other than epilepsy, at lower dosage than indicated in the absence of opiate therapy and titrate based on clinical response700 703

In patients receiving a benzodiazepine, initiate tramadol, if required, at reduced dosage and titrate based on clinical response1 53 59 700 703

Monitor closely for respiratory depression and sedation1 53 59 700 703

Consider offering naloxone to patients receiving opiates and benzodiazepines concomitantly411 431

Bupropion

May inhibit tramadol metabolism, increasing tramadol concentrations and decreasing M1 concentrations; increased tramadol concentrations may increase or prolong therapeutic effects and increase risk of adverse effects (e.g., seizures, serotonin syndrome); decreased M1 concentrations may reduce therapeutic effects and precipitate withdrawal1 53 59

Monitor closely for serious adverse effects (e.g., seizures, serotonin syndrome) and opiate toxicity or withdrawal; if bupropion is discontinued, monitor closely for adverse effects (e.g., respiratory depression, sedation) and consider reducing tramadol dosage until drug effects are stable1 53 59

Buspirone

Risk of serotonin syndrome400

If concomitant use warranted, monitor for serotonin syndrome, particularly during initiation of therapy and dosage increases400

If serotonin syndrome suspected, discontinue tramadol, buspirone, and/or any concurrently administered opiates or serotonergic agents400

Cimetidine

Tramadol pharmacokinetics not altered1 53 59

No dosage adjustment required1 53 59

CNS depressants (e.g., alcohol, anxiolytics, general anesthetics, tranquilizers, phenothiazines, other opiates)

Additive respiratory and CNS depressant effects;1 11 21 38 53 59 increased risk of profound sedation, respiratory depression, hypotension, coma, or death1 53 59 700 703

Other opiate agonists, phenothiazines: Increased risk of seizures1 53 59

Use concomitantly only if alternative treatment options are inadequate; use lowest effective dosages and shortest possible duration of concomitant therapy1 53 59 700 703

In patients receiving tramadol, initiate CNS depressant, if required for any indication other than epilepsy, at lower dosage than indicated in the absence of opiate therapy and titrate based on clinical response700 703

In patients receiving a CNS depressant, initiate tramadol, if required, at reduced dosage and titrate based on clinical response1 53 59 700 703

Monitor closely for respiratory depression and sedation;1 53 59 700 703 with phenothiazines or general anesthetics, also monitor for hypotension1 53 59

Avoid alcohol use1 53 59 700 703

Dextromethorphan

Risk of serotonin syndrome400

If concomitant use warranted, monitor for serotonin syndrome, particularly during initiation of therapy and dosage increases400

If serotonin syndrome suspected, discontinue tramadol, dextromethorphan, and/or any concurrently administered opiates or serotonergic agents400

Digoxin

Digoxin toxicity reported rarely1 53 59

Monitor for digoxin toxicity; adjust digoxin dosage as needed1 53 59

Diuretics

Opiates may decrease diuretic efficacy by inducing vasopressin release1 53 59

Monitor for reduced diuretic and/or BP effects; increase diuretic dosage as needed1 53 59

HIV protease inhibitors (PIs) (e.g., ritonavir)

May decrease tramadol clearance; increased tramadol concentrations may increase M1 formation; increased risk of adverse effects (e.g., seizures, serotonin syndrome) and opiate toxicity1 53 59

Monitor closely for serious adverse effects (e.g., seizures, serotonin syndrome) and opiate toxicity, and consider decreasing tramadol dosage until drug effects are stable; if HIV PI is discontinued, monitor for opiate withdrawal and consider increasing tramadol dosage until drug effects are stable1 53 59

5-HT1 receptor agonists (triptans; e.g., almotriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan)

Risk of serotonin syndrome1 53 59 400

If concomitant use warranted, monitor patient closely, particularly during treatment initiation and dosage increases1 47 53 59 400

If serotonin syndrome suspected, discontinue tramadol,1 53 59 the triptan, and/or any concurrently administered opiates or serotonergic agents400

Lithium

Risk of serotonin syndrome400

If concomitant use warranted, monitor patient closely, particularly during treatment initiation and dosage increases47 400

If serotonin syndrome suspected, discontinue tramadol, lithium, and/or any concurrently administered opiates or serotonergic agents400

Macrolides (erythromycin)

May decrease tramadol clearance; increased tramadol concentrations may increase M1 formation; increased risk of adverse effects (e.g., seizures, serotonin syndrome) and opiate toxicity1 53 59

Monitor closely for serious adverse effects (e.g., seizures, serotonin syndrome) and opiate toxicity, and consider decreasing tramadol dosage until drug effects are stable; if macrolide is discontinued, monitor for opiate withdrawal and consider increasing tramadol dosage until drug effects are stable1 53 59

MAO inhibitors (e.g., isocarboxazid, linezolid, methylene blue, phenelzine, selegiline, tranylcypromine)

Increased risk of adverse effects (e.g., serotonin syndrome, seizures, opiate toxicity)1 53 59 400

Do not use tramadol in patients who are receiving or have recently (within 14 days) received MAO inhibitors1 53 59

If serotonin syndrome suspected, discontinue tramadol, the MAO inhibitor, and/or any concurrently administered opiates or serotonergic agents400

Neuromuscular blocking agents

Possible enhanced neuromuscular blocking effect resulting in increased respiratory depression1 53 59

Monitor for respiratory depression; reduce dosage of one or both agents as necessary1 53 59

Opiate partial agonists (butorphanol, buprenorphine, nalbuphine, pentazocine)

Possible reduced analgesic effect and/or withdrawal symptoms1 53 59

Avoid concomitant use1 53 59

Quinidine

Inhibits tramadol metabolism, increasing tramadol concentrations by 50–60% and decreasing M1 concentrations by 50–60%; increased tramadol concentrations may increase or prolong therapeutic effects and increase risk of adverse effects (e.g., seizures, serotonin syndrome); decreased M1 concentrations may reduce therapeutic effects and precipitate withdrawal1 53 59

Clinical importance of altered tramadol and M1 concentrations not fully established1 53 59

Monitor closely for serious adverse effects (e.g., seizures, serotonin syndrome) and opiate toxicity or withdrawal; if quinidine is discontinued, monitor closely for adverse effects (e.g., respiratory depression, sedation) and consider reducing tramadol dosage until drug effects are stable1 53 59

Rifampin

May increase tramadol metabolism, decreasing tramadol concentrations and reducing efficacy or precipitating opiate withdrawal1 53 59

Monitor for opiate withdrawal and consider increasing tramadol dosage until drug effects are stable; if rifampin is discontinued, monitor for seizures, serotonin syndrome, sedation, and respiratory depression, and consider decreasing tramadol dosage until drug effects are stable1 53 59

Sedative/hypnotic agents (e.g., butabarbital, eszopiclone, pentobarbital, ramelteon, secobarbital, suvorexant, zaleplon, zolpidem)

Risk of profound sedation, respiratory depression, hypotension, coma, or death1 53 59 700 703

Use concomitantly only if alternative treatment options are inadequate; use lowest effective dosages and shortest possible duration of concomitant therapy1 53 59 700 703

In patients receiving tramadol, initiate sedative/hypnotic, if required, at lower dosage than indicated in the absence of opiate therapy and titrate based on clinical response1 53 59 700 703

In patients receiving a sedative/hypnotic, initiate tramadol, if required, at reduced dosage and titrate based on clinical response1 53 59 700 703

Monitor closely for respiratory depression and sedation1 53 59 700 703

Skeletal muscle relaxants (e.g., baclofen, carisoprodol, chlorzoxazone, cyclobenzaprine, dantrolene, metaxalone, methocarbamol, orphenadrine, tizanidine)

Risk of profound sedation, respiratory depression, hypotension, coma, or death1 53 59 700 703

Cyclobenzaprine: Increased risk of adverse effects (e.g., seizures, serotonin syndrome)1 53 59 400

Use concomitantly only if alternative treatment options are inadequate; use lowest effective dosages and shortest possible duration of concomitant therapy1 53 59 700 703

In patients receiving tramadol, initiate skeletal muscle relaxant, if required, at lower dosage than indicated in the absence of opiate therapy and titrate based on clinical response1 53 59 700 703

In patients receiving a skeletal muscle relaxant, initiate tramadol, if required, at reduced dosage and titrate based on clinical response1 53 59 700 703

Monitor closely for respiratory depression and sedation1 53 59 700 703

Cyclobenzaprine: If concomitant use warranted, monitor for serotonin syndrome, particularly during initiation of therapy and dosage increases400

If serotonin syndrome suspected, discontinue tramadol, cyclobenzaprine, and/or any concurrently administered opiates or serotonergic agents400

St. John’s wort (Hypericum perforatum)

May increase tramadol metabolism, decreasing tramadol concentrations and reducing efficacy or precipitating opiate withdrawal1 53 59

Risk of serotonin syndrome1 51 53 400

Monitor for opiate withdrawal and consider increasing tramadol dosage until drug effects are stable; if St. John’s wort is discontinued, monitor for seizures, serotonin syndrome, sedation, and respiratory depression, and consider decreasing tramadol dosage until drug effects are stable1 53 59

If concomitant use warranted, monitor for serotonin syndrome, particularly during treatment initiation and dosage increases1 47 53 59 400

If serotonin syndrome suspected, discontinue tramadol, St. John’s wort, and/or any concurrently administered opiates or serotonergic agents400

Tryptophan

Risk of serotonin syndrome400

If concomitant use warranted, monitor for serotonin syndrome, particularly during initiation of therapy and dosage increases400

If serotonin syndrome suspected, discontinue tramadol, tryptophan, and/or any concurrently administered opiates or serotonergic agents400

Warfarin

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

Use with caution;49 closely monitor INR;48 49 50 adjust warfarin dosage as needed1 53 59

Tramadol Hydrochloride Pharmacokinetics

Absorption

Bioavailability

Rapidly and almost completely absorbed following oral administration; mean absolute bioavailability of conventional tablets is approximately 75%.1 51 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 Extended-release capsules are bioequivalent to extended-release tablets under fasting conditions.59

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 within 12 and 15 hours, respectively, following administration as extended-release tablets;53 and within 6 and 11 hours, respectively, following administration as extended-release capsules.59

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

Tramadol extended-release capsules: Food does not substantially affect rate or extent of absorption.59

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 53 705

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 10 hours (extended-release capsules).59

Racemic M1: Mean terminal plasma elimination half-life is approximately 7 hours (conventional tablets);1 51 53 8.8 hours (extended-release tablets);53 11 hours (extended-release capsules).59

Special Populations

In patients with severe renal impairment, excretion of tramadol and its active metabolite, M1, is reduced.1 51 Extended-release oral formulations not studied in patients with severe renal impairment.53 59

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 oral formulations not studied in patients with severe (Child-Pugh class C) hepatic impairment.53 59

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 53 59

Stability

Storage

Oral

Conventional Tablets

Tight containers at 20–25°C (may be exposed to 15–30°C).1

Extended-release Capsules

Tight containers at 20–25°C (may be exposed to 15–30°C).59

Extended-release Tablets

20–25°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

  • M1 metabolite is 6 times more potent than the parent drug in producing analgesia in animal models and 200 times more potent in μ-receptor binding.1 3 4 51 53

  • Can produce dependence.1 2 3 4 5 6 8 9 11 16 17 53 Although not originally subject to control under the Federal Controlled Substances Act of 1970 as a scheduled drug, became subject to control as schedule IV (C-IV) drug effective August 18, 2014.56

Advice to Patients

  • Importance of reading the patient information (medication guide) provided by the manufacturer before initiating therapy and each time the prescription is refilled.1 53 59

  • Potential for addiction, abuse, and misuse, which can lead to overdosage or death, even when used as recommended.1 53 59 Protect from theft or misuse; properly dispose of any unused drug, and do not share tramadol with others.1 53 59

  • Risk of potentially fatal respiratory depression; most likely to occur following initiation of therapy or increase in dosage; may occur at recommended dosages.1 53 59 Importance of seeking immediate medical attention if signs or symptoms of respiratory depression occur.1 53 59

  • Accidental ingestion, especially by a child, may result in respiratory depression or death.1 53 59 Instruct patient to keep tramadol out of reach of children.1 53 59

  • Risk of potentially fatal additive effects (e.g., profound sedation, respiratory depression, coma) if used concomitantly with benzodiazepines or other CNS depressants, including alcohol and other opiates, either therapeutically or illicitly; avoid concomitant use unless such use is supervised by clinician.1 53 59 700 703 Importance of avoiding alcohol-containing beverages or products.1 53 59 700

  • Potential for seizures and/or serotonin syndrome with concomitant use of serotonergic drugs or drugs that substantially decrease the metabolism of tramadol.1 53 59 400 Importance of immediately contacting clinician if manifestations of serotonin syndrome (e.g., agitation, hallucinations, tachycardia, labile BP, fever, excessive sweating, shivering, shaking, muscle stiffness, twitching, loss of coordination, nausea, vomiting, diarrhea) develop.1 53 59 400

  • Potential for drug to impair mental alertness or physical coordination; avoid driving or operating machinery until effects on individual are known.1 53 59

  • Importance of women informing their clinician if they are or plan to become pregnant or plan to breast-feed.1 53 59 Importance of informing women that tramadol can cause fetal harm and that chronic use during pregnancy may result in neonatal opiate withdrawal syndrome, which can be life-threatening if not recognized and treated.1 53 59

  • Risk of opiate toxicity in nursing infants of women taking tramadol, especially if the woman is an ultrarapid metabolizer of the drug.705 Importance of not taking tramadol while nursing.705 Importance of immediately seeking medical attention if an infant exposed to tramadol through breast milk exhibits symptoms of opiate overdosage (e.g., sedation, difficulty breathing, hypotonia, poor feeding).705

  • Risk of opiate toxicity in children, especially those who are obese, have respiratory diseases, or have evidence of ultrarapid metabolism of tramadol.60 705 Importance of not giving tramadol to children <12 years of age for pain relief or to children <18 years of age for pain relief following tonsillectomy or adenoidectomy.705 Importance of monitoring children receiving tramadol for clinical manifestations of opiate toxicity (e.g., slow, shallow, difficult, or noisy breathing; confusion; unusual sleepiness) and seeking immediate medical attention for the child if symptoms develop.705

  • Importance of taking exactly as prescribed; do not increase dosage or abruptly discontinue without consulting a clinician.1 53 59

  • 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 59

  • Importance of swallowing extended-release tablets or capsules whole; do not crush, chew, break, split, dissolve, or administer by any other route.53 59

  • Advise patients that MAO inhibitors must not be taken with tramadol.1 53 59

  • Potential risk of adrenal insufficiency.1 53 59 400 Importance of contacting clinician if manifestations of adrenal insufficiency (e.g., nausea, vomiting, loss of appetite, fatigue, weakness, dizziness, hypotension) develop.1 53 59 400

  • Potential for severe constipation.1 53 59 Advise patients on appropriate management.1 53 59

  • Risk of orthostatic hypotension and syncope.1 53 59

  • Possible risk (although causality not established) of hypogonadism or androgen deficiency with long-term opiate agonist or partial agonist use.400 Importance of informing clinician if decreased libido, impotence, erectile dysfunction, amenorrhea, or infertility occurs.400

  • Importance of seeking medical attention if symptoms of severe hypersensitivity (e.g., anaphylaxis) occur.1 53 59

  • Importance of informing clinician of existing or contemplated concomitant therapy, including prescription and OTC drugs, as well as any concomitant illnesses.1 53 59

  • Importance of informing patients of other important precautionary information.1 53 59 (See Cautions.)

Preparations

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

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

Subject to control under the Federal Controlled Substances Act of 1970 as schedule IV (C-IV) drug, effective August 18, 2014.56

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

traMADol Hydrochloride

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Oral

Capsules, extended-release

100 mg (with extended-release 75 mg and immediate-release 25 mg)

Conzip (C-IV)

Vertical

200 mg (with extended-release 150 mg and immediate-release 50 mg)

Conzip (C-IV)

Vertical

300 mg (with extended-release 250 mg and immediate-release 50 mg)

Conzip (C-IV)

Vertical

Tablets, extended-release

100 mg*

traMADol Hydrochloride Extended-Release Tablets (C-IV)

Ultram ER (C-IV)

Janssen

200 mg*

traMADol Hydrochloride Extended-Release Tablets (C-IV)

Ultram ER (C-IV)

Janssen

300 mg*

traMADol Hydrochloride Extended-Release Tablets (C-IV)

Ultram ER (C-IV)

Janssen

Tablets, film-coated

50 mg*

traMADol Hydrochloride Tablets (C-IV)

Ultram (C-IV; scored)

Janssen

* 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 with Acetaminophen 325 mg*

traMADol Hydrochloride and Acetaminophen Tablets (C-IV)

Ultracet (C-IV)

Janssen

AHFS DI Essentials. © Copyright 2018, Selected Revisions November 13, 2017. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.

References

1. Janssen Pharmaceuticals, Inc. Ultram (tramadol hydrochloride) tablets prescribing information. Titusville, NJ. 2016 Dec.

2. Lehmann KA. Tramadol for the management of acute pain. Drugs. 1994; 47(Suppl 1):19-32. http://www.ncbi.nlm.nih.gov/pubmed/7517822?dopt=AbstractPlus

3. Dayer P, Collart L, Desmeules J. The pharmacology of tramadol. Drugs. 1994; 47(Suppl 1):3-7. http://www.ncbi.nlm.nih.gov/pubmed/7517823?dopt=AbstractPlus

4. Lee CR, McTavish D, Sorkin EM. Tramadol: a preliminary review of its pharmacodynamic and pharmacokinetic properties, and therapeutic potential in acute and chronic pain states. Drugs. 1993; 46:313-40. http://www.ncbi.nlm.nih.gov/pubmed/7691519?dopt=AbstractPlus

5. Reynolds JEF, ed. Martindale: the extra pharmacopoeia. 30th ed. London: The Pharmaceutical Press; 1993:1097-8.

6. Besson JM, Vickers MD. Tramadol analgesia: synergy in research and therapy. Drugs. 1994; 47(Suppl 1):1-2. http://www.ncbi.nlm.nih.gov/pubmed/7517820?dopt=AbstractPlus

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