How to taper extended release (ER) tramadol (Ultram) 100mg twice daily (bid)?

Tapering Extended Release Tramadol 100mg BID

The most effective approach to tapering extended-release tramadol 100mg twice daily is to reduce the dose by 50mg every 3 days until discontinuation, with a maximum daily dose reduction of 50mg to minimize withdrawal symptoms. 1

Recommended Tapering Schedule

Initial Assessment

• Verify current total daily dose: 200mg (100mg BID)
• Ensure patient is not taking MAOIs (contraindicated) 2
• Check renal function (if CrCl <30 mL/min, maximum dose should be 200mg/day) 2
• Assess for hepatic impairment (requires dose adjustment) 2
• Consider patient age (patients >75 years should not exceed 300mg/day) 1

Tapering Protocol

1. Week 1: Reduce to 150mg daily

   • 100mg in morning, 50mg in evening
   • Maintain this dose for 3 days

2. Week 2: Reduce to 100mg daily

   • 50mg twice daily
   • Maintain this dose for 3 days

3. Week 3: Reduce to 50mg daily

   • 50mg once daily
   • Maintain this dose for 3 days

4. Week 4: Discontinue tramadol completely

Rationale for This Approach

The FDA label for tramadol recommends initiating therapy with a gradual titration regimen, increasing by 50mg every 3 days 1. The same principle applies in reverse for tapering, with reductions of 50mg every 3 days to minimize withdrawal symptoms. This approach is consistent with the CDC guideline recommendation that clinicians should collaborate with patients on a tapering plan for those on high opioid doses 3.

Monitoring During Tapering

• Schedule follow-up visits every 1-4 weeks during the taper 3
• Monitor for withdrawal symptoms: anxiety, insomnia, nausea, diarrhea, muscle aches
• Assess pain control using validated pain scales
• Watch for signs of serotonin syndrome if patient is on other serotonergic medications 2
• Consider offering naloxone if patient is at risk for overdose 3

Managing Withdrawal Symptoms

• For insomnia: Sleep hygiene education, short-term use of non-benzodiazepine sleep aids
• For anxiety: Relaxation techniques, short-term clonidine (0.1-0.2mg every 6 hours as needed)
• For muscle aches: Acetaminophen or NSAIDs if not contraindicated
• For nausea: Antiemetics as needed

Special Considerations

• If withdrawal symptoms are severe, slow the taper to 25mg reductions or extend the interval between dose reductions to 5-7 days
• If the patient has been on extended-release tramadol for a long time (>1 year), consider a more gradual taper with 25mg reductions every 1-2 weeks
• For elderly patients or those with comorbidities, a more conservative approach may be warranted 2
• Avoid abrupt discontinuation to prevent withdrawal symptoms 2

Alternative Approaches for Pain Management

• Consider non-opioid analgesics (NSAIDs, acetaminophen) as baseline therapy 2
• For neuropathic pain components, consider gabapentin (100-300mg TID) or pregabalin 2
• For localized pain, topical lidocaine may be beneficial 2

This tapering schedule balances the need to minimize withdrawal symptoms while ensuring a complete and successful discontinuation of extended-release tramadol. The gradual reduction approach is supported by FDA labeling and clinical guidelines, prioritizing patient safety and comfort during the tapering process.