Tramadol hydrochloride

Con-zip, durela, raliva, tridural, ultram, zytram, XL

Opiate (narcotic) analgesics.

Dosage and freaquency

Adults age 17 and older: Initially, 25 mg (immediate-release) P.O. in the morning. Adjust by 25
mg every 3 days to 100 mg/day (25 mg q.i.d.). Thereafter, adjust by 50 mg every 3 days to reach
200 mg/day (50 mg q.i.d.). Thereafter, give 50 to 100 mg P.O. every daily. 4 to 6 hours p.r.n.
Maximum, 400 mg

Adult’s age 18 and older not taking immediate-release tablets: 100 mg extended-release form
P.O. once daily. Titrate by 100 mg every 5 days to relieve pain. Do not exceed 300 mg/day.
Adults age 18 and older currently taking

Immediate-release tablets: Calculate the 24-hour tramadol immediate-release dose and initiate a
total daily dose of extended- release product rounded down to the next lowest 100-mg increment.
Subsequently, individualize according to patient need. Maximum dose is 300 mg daily

Mechanism of Action

Unknown. Thought to bind to opioid recep-tors and inhibit reuptake of norepinephrine and
serotonin.

Rationale

Tramadol works directly on opioid receptors in the central nervous system and reduces feelings
of pain by interrupting the way nerves signal pain between the brain and the body.

Side effects seen/or possible side effects

CNS: dizziness, headache, somnolence, vertigo, seizures, anxiety, asthenia, CNS stimulation,
confusion, coordination dis- turbance, euphoria, malaise, nervousness, sleep disorder, fever,
paresthesia, tremor, depression, agitation, apathy
CV: vasodilation, hypertension, peripheral edema.
EENT: visual disturbances, nasopharyngi- tis, pharyngitis, rhinitis, sinusitis
GI: constipation, nausea, vomiting, abdominal pain, anorexia, diarrhea, dry mouth,dyspepsia,
flatulence.
GU: menopausal symptoms, proteinuria, urinary frequency, urine retention, pelvic pain, UTI,
prostate disorder.
Metabolic: weight loss.
Musculoskeletal: hypertonia, arthralgia, neck pain, myalgia.
Respiratory: bronchitis, respiratory depression.
Skin: diaphoresis, pruritus, rash.
Other: chills, withdrawal syndrome, acci- dental injury.

Benzodiazepines, CNS depressants: May cause slow or difficult breathing, sedation, and death.
Avoid use together. If use together is neces- sary, limit dosage and duration of each drug to
minimum necessary for desired effect.

Carbamazepine: May increase tramadol metabolism. Patients receiving long-term

carbamazepine therapy up to 800 mg daily may need up to twice the recommended tramadol
dose.

CNS depressants, opioids: May cause ad- ditive effects. Use together cautiously; tram- adol
dosage may need to be reduced

Cyclobenzaprine, MAO inhibitors, neurolep- tics, other opioids, TCAS: May increase risk of
seizures. Monitor patient closely.

CYP2D6 inhibitors: May decrease therapeutic effect of tramadol. Monitor therapy closely

CYP3A4 inducers: May decrease tramadol serum concentra- tion. Monitor therapy closely.

CYP3A4 inhibitors: May increase tramadol serum concentration. Monitor therapy closely

Quinidine: May increase level of tramadol. Monitor patient closely

Serotonergic drugs (amoxapine, antiemetics [dolasetron, granisetron, on- dansetron,

palonosetron], antimigraine drugs, buspirone, cyclobenzaprine, dex- tromethorphan,
linezolid, lithium, MAO inhibitors, maprotiline, methylene blue, mir- tazapine, nefazodone,
SSNRIS, SSRIs, TCAs, trazodone, tryptophan, vilazodone): May increase risk of serotonin
syndrome. Use together cautiously and monitor patient for serotonin syndrome.

Vitamin K antagonists (warfarin): May increase anticoagulant effects. Monitor therapy

closely.

Drugherb.

Kava kava: May increase CNS depression. Monitor therapy closely.

St. John's wort: May increase risk of serotonin syndrome. Use together cautiously and monitor
patient for serotonin syndrome.

Drug-lifestyle.

Alcohol use: May have additive effects. Don't use together

EFFECTS ON LAB TEST RESULTS

- May increase creatinine, GGT, and liver enzyme levels.

- May decrease Hb level.

PREGNANCY-LACTATION-REPRODUCTION

Safe use in pregnant women hasn't been established. Use only if potential benefit justifies
potential risk to the fetus. Prolonged use during pregnancy can result in neonatal opioid
withdrawal syndrome, which may be life- threatening if not recognized and treated according to
neonatology expert protocols. If opioid use is required for a prolonged

NURSING CONSIDERATIONS

Caution patient or caregiver of patient taking an opioid with a benzodiazepine, CNS depressant,
or al- cohol to seek immediate medical attention for dizziness, light-headedness, extreme
sleepiness, slowed or difficult breathing, or unresponsiveness.

Tramadol exposes patients to the risk of addiction, abuse, and misuse, which can lead to
overdose and death. Assess each patient's risk before prescribing; monitor patient regularly for
development of abnormal behaviors.

• Reassess patient's level of pain at least 30 minutes after administration.

• Monitor CV and respiratory status. Withhold dose and notify prescriber if respirations are
shallow or rate is below 12 breaths/minute.

Carefully monitor vital signs, pain level, respiratory status, and sedation level in all patients
receiving opioids, especially those receiving I.V. drugs, even those given postoperatively.
 • Monitor bowel and bladder function. Anticipate need for stimulant laxative. For better
analgesic effect, give drug before onset of intense pain.

• Monitor patients at risk for seizures. Drug may reduce seizure threshold.

• In the case of an overdose, naloxone may also increase risk of seizures.

• Monitor patient for drug dependence. Drug can produce dependence similar to that of
codeine and thus has potential for abuse

• Withdrawal symptoms may occur if drug is stopped abruptly. Reduce dosage gradually

If patient is taking opioids with serotonergic drugs, watch for signs and symptoms of serotonin
syndrome (agitation,hallucinations, rapid HR, fever, excessive sweating, shivering or shaking,
muscle twitching or stiffness, trouble with coordi nation, nausea, vomiting, diarrhea), espe- cially
when starting treatment or increasing dosages. Signs and symptoms may occur within several
hours of coadministration but may also occur later, especially after dosage increase. Discontinue
the opioid, seroton- ergic drug, or both if serotonin syndrome is suspected.

Monitor patient for signs and symp toms of adrenal insufficiency (nausea, vom- iting, loss of
appetite, fatigue, weakness, dizziness, low BP). Perform diagnostic test- ing if adrenal
insufficiency is suspected. If adrenal insufficiency is confirmed, treat with corticosteroids and
wean patient off opioids if appropriate. Discontinue corticosteroids when clinically appropriate.

Monitor patient for signs and symp- toms of decreased sex hormone levels (low libido, erectile
dysfunction, amenorrhea, infertility). If signs and symptoms occur, evaluate patient and obtain
laboratory testing.

Don't confuse tramadol with trazodone or trandolapril.