What is the maximum recommended dose of tramadol (ultram)?

Maximum Recommended Dose of Tramadol

The maximum recommended daily dose of tramadol is 400 mg for adults, with a reduced maximum of 300 mg/day for elderly patients over 75 years old. 1

Standard Dosing Guidelines

• Initial dosing:

  • 50-100 mg every 4-6 hours as needed for pain relief 1
  • For improved tolerability, start with a titration regimen:
    • Begin at lower doses and increase by 50 mg every 3 days as tolerated 1
    • Gradually increase to reach 200 mg/day (50 mg four times daily) 1

• Maximum daily limits:

  • Regular adults: 400 mg/day 1, 2
  • Extended-release formulations: 300 mg/day 2
  • Elderly patients over 75 years: 300 mg/day 1, 2

Special Population Considerations

Renal Impairment

• For patients with creatinine clearance <30 mL/min:
  • Increase dosing interval to 12 hours 1
  • Maximum daily dose: 200 mg 1, 2
  • Hemodialysis patients can receive their regular dose on dialysis days (only 7% removed by dialysis) 1

Hepatic Impairment

• For patients with cirrhosis:
  • Recommended dose: 50 mg every 12 hours 1, 2
  • Bioavailability increases 2-3 fold in these patients 2

Elderly Patients

• For patients over 65 years:
  • Start at the low end of the dosing range 1
  • Consider decreased hepatic, renal, or cardiac function 1
• For patients over 75 years:
  • Maximum daily dose: 300 mg/day 1, 2

Pharmacological Properties

• Tramadol has a dual mechanism of action:
  • Weak μ-opioid receptor agonist (approximately one-tenth as potent as morphine) 2, 3
  • Inhibits reuptake of norepinephrine and serotonin 3
• Onset of action: Within 1 hour of oral administration 3, 4
• Duration of analgesic effect: Approximately 6 hours after a single 100 mg oral dose 3

Safety Considerations

• Common side effects include:
  • Dizziness, nausea, sedation, dry mouth, and sweating 2, 4
  • Side effects are dose-dependent, particularly nausea 3
• Important precautions:
  • Do not administer to patients taking monoamine oxidase inhibitors 3
  • Use cautiously with other serotonergic medications due to risk of serotonin syndrome 2
  • Avoid combination with tricyclic antidepressants if possible 3
  • Lower risk of respiratory depression compared to other opioids 4

Clinical Pearl

Starting at the lowest possible dose and gradually titrating upward results in fewer discontinuations and increased tolerability 1. For chronic pain management, the sustained-release formulation may be beneficial, allowing for twice-daily dosing instead of four times daily dosing 5.