Can tramadol (ultram) cause hypotension?

From the Guidelines

Tramadol can cause hypotension, particularly when taken at higher doses or in combination with other medications that lower blood pressure. According to the most recent evidence 1, tramadol is a weak mu-opioid receptor agonist with some norepinephrine and serotonin reuptake inhibition, which can lead to peripheral vasodilation and subsequently cause hypotension. The risk of hypotension is increased in patients who are already taking medications that lower blood pressure, are dehydrated, or have underlying cardiovascular conditions.

Some key points to consider when taking tramadol include:

• Taking the medication exactly as prescribed to minimize the risk of hypotension
• Staying well-hydrated to reduce the risk of dehydration, which can exacerbate hypotension
• Avoiding alcohol and other central nervous system depressants while using tramadol, as they can increase the risk of hypotension and other adverse effects
• Monitoring for symptoms of low blood pressure, such as dizziness, lightheadedness, or fainting, and contacting a healthcare provider immediately if these symptoms occur

It's worth noting that the evidence from 1 suggests that tramadol is less potent than other opioids and is considered to be approximately one-tenth as potent as morphine. However, this does not necessarily reduce the risk of hypotension, and patients should still be cautious when taking this medication.

In terms of dosage, the NCCN panel recommends a maximum daily dose of 400 mg for immediate-release formulations and 300 mg/day for extended-release formulations, for adults with normal hepatic and renal function 1. Lower doses are recommended for older adults and those with hepatic and/or renal dysfunction to reduce the risk of seizures.

From the FDA Drug Label

At therapeutic doses, tramadol hydrochloride has no effect on heart rate, left-ventricular function or cardiac index. Orthostatic hypotension has been observed. Acute overdosage with tramadol can be manifested by ... hypotension, ...

• Hypotension can be a side effect of tramadol, specifically orthostatic hypotension at therapeutic doses, and more severe hypotension in cases of overdose 2 2.
• Tramadol can cause hypotension, particularly in certain situations such as orthostatic changes or overdose.

From the Research

Tramadol and Hypotension

• Tramadol is a centrally acting analgesic that has been shown to be effective in a variety of acute and chronic pain states 3.
• Unlike other centrally acting analgesics, it exerts a dual action by binding to the opioid receptor site in the central nervous system and by weakly inhibiting the reuptake of biogenic amines.
• The use of tramadol does not aggravate hypertension or congestive heart failure, nor does it have the potential to cause peptic ulcer disease 3.
• Postural hypotension played almost no role in the multiple dose studies, in which the oral formulation were used most frequently 4.
• The central-acting analgesic tramadol exerted no prohypertensive effect and it did not increase BP values, and in fact, tramadol would appear to be particularly useful in the elderly population affected by osteoarthritis because it does not aggravate hypertension 3, 5.
• However, other studies have reported that certain antidepressant drugs, which have similar mechanisms of action to tramadol, can lead to orthostatic hypotension, especially in patients with cardiovascular diseases 6.
• It is worth noting that tramadol can cause dizziness, which may be related to its effects on blood pressure 4.

Comparison with Other Medications

• Non-steroidal anti-inflammatory drugs (NSAIDs) can have a prohypertensive effect, which can be manifested by the decreased efficiency of antihypertensive therapy 5.
• The prohypertensive effect of the tested NSAIDs increases in the following order: tramadol, ketoprofen, meloxicam, nimesulide, arthrotec, diclofenac 5.
• Tramadol has a safer profile compared to NSAIDs in terms of its effect on blood pressure 5.

Side Effects

• The most commonly observed side effects of tramadol were nausea, dizziness, drowsiness, tiredness, sweating, vomiting, and dry mouth, with an overall incidence of between 1 and 6% 4.
• Tramadol can also cause seizures, serotonin syndrome, and other neurological disorders, especially with long-term use 7.