UK Edition. Click here for US version.
TRAMULIEF SR 200MG PROLONGED-RELEASE TABLETS
Active substance(s): TRAMADOL HYDROCHLORIDE / TRAMADOL HYDROCHLORIDE
NAME OF THE MEDICINAL PRODUCT
Tramulief SR 200 mg prolonged-release tablets
QUALITATIVE AND QUANTITATIVE COMPOSITION
One prolonged-release tablet contains 200 mg tramadol hydrochloride.
For a full list of excipients, see section 6.1.
Tramulief SR 200 mg prolonged-release tablets are off white, capsule shaped tablets,
17.1 mm long.
Treatment of moderate to severe pain.
Posology and method of administration
Route of Administration
The dose should be adjusted to the intensity of the pain and the sensitivity of the
individual patient. The lowest effective dose for analgesia should generally be
Unless otherwise prescribed, Tramulief SR prolonged-release tablets should be given
Adults and adolescents older than 12 years:
The usual initial dose is 50 – 100 mg tramadol hydrochloride twice daily, morning
and evening. If pain relief is insufficient, the dose may be titrated upwards to 150 mg
or 200 mg tramadol hydrochloride twice daily.
For doses not practicable with this strength, other strengths of this medicinal product
Tramulief SR prolonged-release tablets should be swallowed completely, without
breaking or chewing, independent of meals, with sufficient liquid.
Daily doses of 400 mg of active substance should not be exceeded, except in special
Under no circumstances should Tramulief SR be used for longer than absolutely
necessary. If long-term pain treatment with tramadol is necessary in view of the
nature and severity of the illness, then careful and regular monitoring should be
carried out (if necessary with breaks in treatment) to establish whether, and to what
extent, further treatment is necessary.
Tramulief SR is not suitable for children under the age of 12 years.
A dose adjustment is not usually necessary in patients up to 75 years without any
clinically manifest hepatic or renal insufficiency. In elderly patients over 75 years
elimination may be prolonged. Therefore, if necessary the dosage interval is to be
extended according to the patient’s requirements.
Renal insufficiency/dialysis and hepatic impairment
In patients with renal and/or hepatic insufficiency the elimination of tramadol is
delayed. In these patients prolongation of the dosage interval should be carefully
considered according to the patient’s requirements.
Tramulief SR prolonged-release tablets are contraindicated:
in hypersensitivity to tramadol hydrochloride, or to any of the excipients
listed in section 6.1;
in acute intoxication with alcohol, hypnotics, analgesics, opioids or
psychotropic medicinal products;
in patients receiving MAO inhibitors, or who have taken them within the last
14 days (see section 4.5);
in patients with epilepsy not adequately controlled by treatment;
for use in narcotic withdrawal treatment.
Special warnings and precautions for use
Tramulief SR may only be used with particular caution in opioid-dependent patients,
patients with head injury, shock, a reduced level of consciousness of uncertain origin,
disorders of the respiratory centre or function, or increased intracranial pressure.
In patients sensitive to opiates the product should only be used with caution.
Care should be taken when treating patients with respiratory depression, or if
concomitant CNS depressant drugs are being administered (see section 4.5), or if the
recommended dosage is significantly exceeded (see section 4.9) as the possibility of
respiratory depression cannot be excluded in these situations.
Convulsions have been reported in patients receiving tramadol at the recommended
dose levels. The risk may be increased when doses of tramadol exceed the
recommended upper daily dose limit (400 mg).
In addition tramadol may increase the seizure risk in patients taking other medicinal
products that lower the seizure threshold (see section 4.5.). Patients with epilepsy or
those susceptible to seizures should only be treated with tramadol if there are
Tramadol has a low dependence potential. On long-term use tolerance, psychic and
physical dependence may develop. In patients with a tendency to drug abuse or
dependence, treatment with Tramulief SR should only be carried out for short periods
under strict medical supervision.
Tramadol is not suitable as a substitute in opioid-dependent patients. Although it is an
opioid agonist, tramadol cannot suppress morphine withdrawal symptoms.
Interaction with other medicinal products and other forms of interaction
Tramulief SR should not be combined with MAO-inhibitors (see section 4.3).
In patients treated with MAO inhibitors in the 14 days prior to the use of the opioid
pethidine, life threatening interactions on the central nervous system, respiratory and
cardiovascular function have been observed. The same interactions with Tramulief
SR as with MAO inhibitors cannot be ruled out during treatment with Tramulief SR.
Concomitant administration of Tramulief SR with other centrally depressant
medicinal products, including alcohol, may potentiate the CNS effects (see section
The results of pharmacokinetic studies have so far shown that on the concomitant or
previous administration of cimetidine (enzyme inhibitor) clinically relevant
interactions are unlikely to occur. Simultaneous or previous administration of
carbamazepine (enzyme inducer) may reduce the analgesic effect and shorten the
duration of the action.
The combination of mixed agonists/antagonists (e.g. buprenorphine, nalbuphine,
pentazocine) and tramadol is not advisable because the analgesic effect of a pure
agonist may be theoretically reduced in such circumstances.
Tramadol can induce convulsions and increase the potential for selective serotonin
reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs),
tricyclic antidepressants, antipsychotics and other seizure threshold-lowering
medicinal products (such as bupropion, mirtazapine, tetrahydrocannabinol) to cause
Concomitant therapeutic use of tramadol and serotonergic drugs, such as selective
serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors
(SNRIs), MAO inhibitors (see section 4.3), tricyclic antidepressants and mirtazapine
may cause serotonin toxicity. Serotonin syndrome is likely when one of the following
inducible or ocular clonus with agitation or diaphoresis;
tremor and hyperreflexia;
hypertonia and body temperature > 38 °C and inducible or ocular clonus.
Withdrawal of the serotonergic drugs usually brings about a rapid improvement.
Treatment depends on the type and severity of the symptoms.
Caution should be exercised during concomitant treatment with tramadol and
coumarin derivatives (e.g. warfarin) due to reports of increased INR and ecchymoses
in some patients.
Other active substances known to inhibit CYP3A4, such as ketoconazole and
erythromycin, might inhibit the metabolism of tramadol (N-demethylation) and
probably also the metabolism of the active O-demethylated-metabolite. The clinical
importance of such an interaction has not been studied (see section 4.8).
In a limited number of studies the pre – or postoperative application of the antiemetic
5 – HT3 antagonist ondansetron increased the requirement of tramadol in patients
with postoperative pain.
Fertility, Pregnancy and lactation
Animal studies with tramadol revealed at very high doses effects on organ
development, ossification and neonatal mortality. Teratogenic effects were not
observed. Tramadol crosses the placenta. There is inadequate evidence available on
the safety of tramadol in human pregnancy. Therefore Tramulief SR should not be
used in pregnant women.
Tramadol – administered before or during birth – does not affect uterine contractility.
In neonates it may induce changes in the respiratory rate which are usually not
clinically relevant. Chronic use during pregnancy may lead to neonatal withdrawal
symptoms. During lactation about 0.1% of the maternal dose administered is secreted
in the milk. Tramulief SR is not recommended during breast-feeding. After a single
administration of tramadol it is not usually necessary to interrupt breast-feeding.
Effects on ability to drive and use machines
Even when taken according to instructions, Tramulief SR may cause effects
such as somnolence and dizziness and therefore may impair the reactions of
drivers and machine operators. This applies particularly in conjuction with
other psychotropic substances and alcohol. .
This medicine can impair cognitive function and can affect a patient’s ability
to drive safely. This class of medicine is in the list of drugs included in
regulations under 5a of the Road Traffic Act 1988. When prescribing this
medicine, patients should be told:
The medicine is likely to affect your ability to drive
Do not drive until you know how the medicine affects you
It is an offence to drive while under the influence of this medicine
However, you would not be committing an offence (called ‘statutory
o The medicine has been prescribed to treat a medical or dental problem and
o You have taken it according to the instructions given by the prescriber and in
the information provided with the medicine and
o It was not affecting your ability to drive safely
The most commonly reported adverse reactions are nausea and dizziness, both
occurring in more than 10% of patients.
The frequencies are defined as follows:
Very common: ≥1/10
Common: ≥1/100, <1/10
Uncommon: ≥1/1000, <1/100
Rare: ≥1/10 000, <1/1000
Very rare (< 1/10,000)
Not known (cannot be estimated from the available data).
Uncommon: effects on cardiovascular regulation (palpitation, tachycardia, postural
hypotension or cardiovascular collapse). These adverse effects may occur especially
on intravenous administration and in patients who are physically stressed.
Rare: bradycardia, increase in blood pressure.
Nervous system disorders:
Very common: dizziness.
Common: headache, somnolence.
Rare: changes in appetite, paraesthesia, tremor, respiratory depression, epileptiform
convulsions, involuntary muscle contractions, abnormal coordination and syncope.
Not known: speech disorders.
If the recommended doses are considerably exceeded and other centrally depressant
substances are administered concomitantly (see section 4.5) respiratory depression
Epileptiform convulsions occurred mainly after administration of high doses of
tramadol or after concomitant treatment with drugs, which can lower the seizure
threshold or themselves induce cerebral convulsions (see section 4.4 and section 4.5).
Rare: hallucinations, confusion, anxiety, sleep disturbances and nightmares. Psychic
adverse reactions may occur following administration of Tramulief SR which vary
individually in intensity and nature (depending on personality and duration of
treatment). These include changes in mood (usually elation, occasionally dysphoria),
changes in activity (usually suppression, occasionally increase) and changes in
cognitive and sensorial capacity (e.g. decision behaviour, perception disorders).
Dependence may occur.
Rare: blurred vision.
Not known: mydriasis.
Worsening of asthma has been reported, though a causal relationship has not been
Very common: nausea.
Common: vomiting, constipation, dry mouth.
Uncommon: Retching, gastrointestinal irritation (a feeling of pressure in the stomach,
Skin and subcutaneous disorders:
Uncommon: dermal reactions (e.g. pruritus, rash, urticaria).
Rare: motorial weakness.
In a few isolated cases an increase in liver enzyme values has been reported in a
temporal connection with the therapeutic use of tramadol.
Renal and urinary system disorders:
Rare: micturition disorders (difficulty in passing urine, dysuria and urinary retention).
Rare: Allergic reactions (e.g. dyspnoea, bronchospasm, wheezing, angioneurotic
oedema) and anaphylaxis. Symptoms of withdrawal reactions, similar to those
occurring during opiate withdrawal, may occur as follows; agitation, anxiety,
nervousness, insomnia, hyperkinesia, tremor and gastro intestinal symptoms.
Other symptoms that have very rarely been seen with tramadol discontinuation
include: panic attacks, severe anxiety, hallucinations, paraesthesias, tinnitus, and
unusual CNS symptoms (i.e. confusion, delusions, depersonalisation, derealisation,
In tramadol intoxication, in principle, the same symptoms occur as for all other
central acting analgesics (opioids). In particular, these include miosis, vomiting,
cardiovascular collapse, consciousness disorders up to coma, convulsions and
respiratory depression up to respiratory arrest.
General emergency measures apply. Keep the respiratory tract open (aspiration),
maintain respiration and circulation depending on the symptoms. The antidote for
respiratory depression is naloxone. In animal experiments naloxone had no effect on
convulsions. In such case diazepam should be given intravenously.
In case of intoxication orally, gastrointestinal decontamination with activated
charcoal or by gastric lavage is only recommended within 2 hours after tramadol
intake. Gastrointestinal decontamination at a later time point may be useful in case of
intoxication with exceptionally large quantities or prolonged-release formulations.
Tramadol is minimally eliminated from the serum by haemodialysis or
haemofiltration. Therefore treatment of acute intoxication with Tramulief SR with
haemodialysis or haemofiltration alone is not suitable for detoxification.
Pharmacotherapeutic group: other opioids. ATC code N 02 AX 02:
Tramadol is a centrally acting opioid analgesic.
It is a non-selective, partial agonist of μ-, δ- and κ-opioid receptors with a higher
affinity for μ-receptors. Other mechanisms contributing to the analgesic effect are the
inhibition of the neural noradrenaline reuptake, and an enhancement of serotonin
Tramadol has an antitussive action. In contrast to morphine, analgesic doses of
tramadol over a wide range have no respiratory depressant effect. Also
gastrointestinal motility is less affected. Effects on the cardiovascular system tend to
be slight. The potency of tramadol is reported to be 1/10 (one tenth) to 1/6 (one sixth)
that of morphine.
Effects of enteral and parenteral administration of tramadol have been investigated in
clinical trials involving more than 2000 paediatric patients ranging in age from
neonate to 17 years of age. The indications for pain treatment studied in those trials
included pain after surgery (mainly abdominal), after surgical tooth extractions, due
to fractures, burns and traumas as well as other painful conditions likely to require
analgesic treatment for at least 7 days.
At single doses of up to 2 mg/kg or multiple doses of up to 8 mg/kg per day (to a
maximum of 400 mg per day) efficacy of tramadol was found to be superior to
placebo, and superior or equal to paracetamol, nalbuphine, pethidine or low dose
morphine. The conducted trials confirmed the efficacy of tramadol. The safety profile
of tramadol was similar in adult and paediatric patients older than 1 year (see section
More than 90% of tramadol is absorbed after oral administration. The mean absolute
bioavailability is approximately 70 %, irrespective of concomitant intake of food.
The difference between absorbed and non-metabolised available tramadol is probably
due to low first-pass effect. The first-pass effect after oral administration is a
maximum of 30 %.
Tramadol has a high tissue affinity (V = 203 ± 40 l). Protein binding is about 20 %.
After administration of tramadol SR 100 mg tablets the peak plasma concentration
C 141 ± 40 ng / ml is reached after 4.9 hours. After administration of tramadol SR
200 mg tablets a C
260 ± 62 ng / ml is reached after 4.8 hours.
Tramadol passes the blood-brain and placenta barrier. Very small amounts of the
substance and its O-desmethyl derivative are found in the breast milk (0.1 % and 0.02
% respectively of the applied dose).
Elimination half-life t½β is approximately 6 h, irrespective of the mode of
administration. In patients above 75 years of age it may be prolonged by a factor of
In humans tramadol is mainly metabolised by means of N- and O-demethylation and
conjugation of the O-demethylation products with glucuronic acid. Only Odesmethyltramadol is pharmacologically active. There are considerable
interindividual quantitative differences between the other metabolites. So far, eleven
metabolites have been found in the urine. Animal experiments have shown that Odesmethyltramadol is more potent than the parent substance by the factor 2 – 4. Its
half-life t½β (6 healthy volunteers) is 7.9 h (range 5.4 – 9.6 h) and is approximately
that of tramadol.
The inhibition of one or both cytochrome P450 isoenzymes, CYP3A4 and CYP2D6
involved in the metabolism of tramadol, may affect the plasma concentration of
tramadol or its active metabolite. Up to now, clinically relevant interactions have not
Tramadol and its metabolites are almost completely excreted via the kidneys.
Cumulative urinary excretion is 90 % of the total radioactivity of the administered
dose. In cases of impaired hepatic and renal function the half-life may be slightly
prolonged. In patients with cirrhosis of the liver, elimination half-lives of 13.3 ± 4.9 h
(tramadol) and 18.5 ± 9.4 h (O-desmethyltramadol), in an extreme case 22.3 h and 36
h respectively have been determined. In patients with renal insufficiency (creatinine
clearance < 5 ml / min) the values were 11 ± 3.2 h and 16.9 ± 3 h, in an extreme case
19.5 h and 43.2 h, respectively.
Tramadol has a linear pharmacokinetic profile within the therapeutic dosage range.
The relationship between serum concentrations and the analgesic effect is dosedependent, but varies considerably in isolated cases. A serum concentration of 100 –
300 ng / ml is usually effective.
The pharmacokinetics of tramadol and O-desmethyltramadol after single-dose and
multiple-dose oral administration to subjects aged 1 year to 16 years were found to be
generally similar to those in adults when adjusting for dose by body weight, but with
a higher between-subject variability in children aged 8 years and below.
In children below 1 year of age, the pharmacokinetics of tramadol and Odesmethyltramadol have been investigated, but have not been fully characterized.
Information from studies including this age group indicates that the formation rate of
O-desmethyltramadol via CYP2D6 increases continuously in neonates, and adult
levels of CYP2D6 activity are assumed to be reached at about 1 year of age. In
addition, immature glucuronidation systems and immature renal function may result
in slow elimination and accumulation of O-desmethyltramadol in children under 1
year of age.
Preclinical safety data
In repeated oral and parenteral administration of tramadol during 6 to 26 weeks to rats
and dogs and oral administration for 12 months in dogs haematological, clinicochemical and histological investigations showed no evidence of any substance-related
changes. Central nervous manifestations only occurred after high doses considerably
above the therapeutic range: restlessness, salivation, convulsions, and reduced weight
gain. Rats and dogs tolerated oral doses of 20 mg/kg and 10 mg/kg body weight
respectively, and dogs rectal doses of 20 mg/kg body weight without any reactions.
In rats tramadol dosages from 50 mg/kg/day upwards caused toxic effects in dams
and raised neonate mortality. In the offspring retardation occurred in the form of
ossification disorders and delayed vaginal and eye opening. Male fertility was not
affected. After higher doses (from 50 mg/kg/day upwards) females exhibited a
reduced pregnancy rate. In rabbits there were toxic effects in dams from 125 mg/kg
upwards and skeletal anomalies in the offspring.
In some in-vitro test systems there was evidence of mutagenic effects. In-vivo studies
showed no such effects. According to knowledge gained so far, tramadol can be
classified as non-mutagenic.
Studies on the tumorigenic potential of tramadol hydrochloride have been carried out
in rats and mice. The study in rats showed no evidence of any substance-related
increase in the incidence of tumours. In the study in mice there was an increased
incidence of liver cell adenomas in male animals (a dose-dependent, non-significant
increase from 15 mg/kg upwards) and an increase in pulmonary tumours in females
of all dosage groups (significant, but not dose-dependent).
List of excipients
Calcium hydrogen phosphate dihydrate (E341),
Colloidal anhydrous silica (E551),
Magnesium stearate (E470b).
PP/PE tablet container: 6 months after opening
Special precautions for storage
This medicinal product does not require any special storage conditions.
Nature and contents of container
Al / clear PVC blisters in carton boxes in packs of 10, 20, 30, 50, 60, 90, 100, 120,
180, and 500 tablets.
Al / opaque PVC child resistant blisters in carton boxes in packs of 10, 20, 30, 50, 60,
90, 100, 120, 180, and 500 tablets.
Polypropylene tablet container with polyethylene tamper evident closure containing
10, 20, 30, 50, 60, 90, 100, 120, 180, and 500 tablets.
Not all pack sizes may be marketed.
Special precautions for disposal
No special requirements
MARKETING AUTHORISATION HOLDER
Amdipharm UK Limited
85 King William Street,
London, EC4N 7BL,
MARKETING AUTHORISATION NUMBER(S)
DATE OF FIRST AUTHORISATION/RENEWAL OF THE
DATE OF REVISION OF THE TEXT
Source: Medicines and Healthcare Products Regulatory Agency