Tramadol

1. Mechanism
   1. Opiate Analgesic (Codeine analog)
   2. Weak mu-receptor binding
   3. Inhibits Norepinephrine and Serotonin reuptake
   4. Reported low abuse and addiction potential
2. Efficacy
   1. Equivalent effect to Tylenol with codeine (Tylenol #3)
3. Dosing
   1. Usual dose: 50-100 mg q4-6 hours
4. Dosing: Maximum dose per day
   1. Healthy patient: 400 mg/day
   2. Over age 75 years: 300 mg/day
   3. Renal Insufficiency (Creatinine Clearance <30 ml/min)
      1. Reduce dosing frequency to every 12 hours
      2. Do not exceed 200 mg per day
5. Disadvantages
   1. More expensive and lower efficacy than other Narcotics
6. Contraindications
   1. See drug interactions below
   2. Seizure disorder or increased Seizure risk factors
7. Drug Interactions
   1. CYP 2D6 Inhibitors
      1. Block metabolism of Tramadol to active ingredient
         1. Increased adverse effects and decreased efficacy when used in combination with Tramadol
         2. Unique to Tramadol (other Opioids do not have some interaction)
      2. Paroxetine (Paxil)
      3. Fluoxetine (Prozac)
   2. Opioids
      1. Avoid use with other opiates (no benefit)
   3. Serotonin Syndrome (try to avoid combination with other serotonergic agents)
      1. MAO inhibitors (absolute contraindication)
      2. Linezolid (Zyvox)
      3. Selective Serotonin Reuptake Inhibitors (SSRI)
      4. Serotonin Norepinephrine Reuptake Inhibitors (SNRI)
      5. Tricyclic Antidepressants
   4. Seizures
      1. Opioids
      2. Bupropion
      3. Selective Serotonin Reuptake Inhibitors (SSRI)
      4. Tricyclic Antidepressants
      5. Antipsychotic medications
   5. Warfarin
      1. Tramadol may increase INR
      2. Recheck INR three days after starting Tramadol
   6. References
      1. (2012) Presc Lett 19(3): 17