Maximum Recommended Dose of Tramadol Per Day
The maximum recommended daily dose of tramadol is 400 mg per day for adults with normal renal and hepatic function, as stated in the FDA drug label. 1
Dosing Guidelines
Standard Adult Dosing
- Initial dosing: 50-100 mg every 4-6 hours as needed for pain relief 1
- Titration schedule for improved tolerability:
- Start with lower doses and increase by 50 mg every 3 days
- Reach 200 mg/day (50 mg four times daily)
- After titration, 50-100 mg can be administered every 4-6 hours as needed 1
Special Populations
Renal Impairment
- For patients with creatinine clearance <30 mL/min:
- Increase dosing interval to 12 hours
- Maximum daily dose: 200 mg 1
- Hemodialysis patients can receive their regular dose on dialysis days as only 7% of the dose is removed by hemodialysis 1
Hepatic Impairment
- For patients with cirrhosis: 50 mg every 12 hours 1
Elderly Patients
- Age >65 years: Start at the low end of dosing range
- Age >75 years: Total dose should not exceed 300 mg/day 1
Mechanism of Action and Considerations
Tramadol has a dual mechanism of action:
- Weak μ-opioid receptor agonist
- Inhibitor of serotonin and norepinephrine reuptake 2
This dual mechanism contributes to its analgesic effects but also creates potential risks:
- Increased risk of seizures, especially in patients with seizure disorders 2
- Risk of serotonin syndrome when combined with other serotonergic medications 2
Clinical Applications
Tramadol is effective for various pain conditions:
- Moderate to moderately severe chronic pain 1
- Neuropathic corneal pain (at doses up to 400 mg daily) 3
- Cancer pain (as a second-line agent when first-line medications fail) 3
Important Precautions
- Tramadol has approximately one-tenth the potency of morphine 2
- Regular administration rather than "as needed" may be more effective for chronic pain 4
- Common side effects include nausea, vomiting, constipation, dizziness, and sedation 1, 5
- Nausea is dose-dependent and can be reduced by slow titration 6
- Avoid use in patients taking monoamine oxidase inhibitors 6
- Use with caution in patients taking tricyclic antidepressants 6
Formulations
Tramadol is available in:
- Immediate-release formulations (onset of action within 1 hour) 4
- Sustained-release formulations (allowing for twice-daily dosing) 7
- Rectal formulations (alternative when oral route is unavailable) 8
Remember that while the maximum recommended dose is 400 mg per day, the dose should be reduced in special populations, and the lowest effective dose should be used to minimize adverse effects.