Tramadol

Indications

Moderate pain (includes fixed-dose combination with paracetamol). Acute or chronic pain

See full list of Adverse Effects for opioid analgesics.

Specific to Tramadol

50–100 mg every 4–6 hours, up to a total daily dose of 600 mg (maximum 300 mg daily if >75 years).
Nausea and vomiting are more likely with IV bolus doses >50 mg

50–100 mg every 4–6 hours when necessary; maximum 400 mg daily (or 300 mg daily if >75 years).

50–200 mg every 12 hours; maximum 400 mg daily (or 300 mg daily if >75 years). Do not use controlled release product for initial stabilisation.

Start with 100 mg once daily; usual dose 200 mg once daily (maximum 400 mg once daily). Do not use controlled release product for initial stabilisation.

For adult, initially 2 tablets (of paracetamol 325mg and tramadol 37.5 mg), then 1 to 2 tablets every 6 hours if needed. Maximum of 8 tablets in 24 hours

Give IV injection over 2 to 3 minutes; nausea and vomiting are more likely after rapid injection.

Treatment with, or within 14 days of, a MAOI is contraindicated due to risk of serotonin toxicity.
Treatment with other drugs that may contribute to serotonin toxicity may increase likelihood; avoid combinations or monitor clinical course carefully.

Rate of excretion of tramadol and its active metabolite are decreased in renal impairment. Avoid if CrCl <10 mL/minute; reduce dose if CrCl <30 mL/minute (24 hour controlled release product is contraindicated in this situation).

In severe hepatic impairment reduce the dose of parenteral and immediate release oral products; do not use controlled release products.

Limited data available. Although the manufacturer does not recommend use in children, it is used by some specialist paediatricians.

analgesia starts within 1 hour of oral administration, peaks at 2–4 hours
do not use controlled release products for acute pain management as slow onset and offset make rapid, safe titration impossible
6–10% of Caucasians and 1–2% of Asians lack the enzyme CYP2D6 (necessary for metabolism of tramadol to the active metabolite O‑desmethyltramadol); these people may obtain reduced analgesia with tramadol
if maximum doses are not fully effective, consider alternative opioid (e.g. morphine) and/or seek specialist advice
tramadol has relatively weak affinity for opioid receptors and the misuse potential appears to be low; it is designated as a Schedule 4 product and not a controlled substance
atypical withdrawal symptoms (e.g. severe anxiety, panic attacks, hallucinations, paraesthesia, tinnitus) have been reported
naloxone only partially antagonises tramadol overdose, and may increase the risk of seizures

Consider using paracetamol and tramadol separately to optimise analgesia, because the maximum recommended dosage of the fixed dose combination is only 2.6 g paracetamol and 300 mg tramadol daily

Tramadol hydrochloride 50, 100, 150, 200 mg – modified release tablets, twice daily (e.g. Zydol SR®, Tramal SR®)
Tramadol hydrochloride 100, 200, 300 mg - extended release, once daily (Durotram XR®), non PBS
Tramadol hydrochloride 100 mg/2 mL – injection
Tramadol hydrochloride 100 mg/mL – oral liquid