Starting Dose for Tramadol
For patients with moderate to moderately severe pain, the recommended starting dose of tramadol is 50 mg orally every 4-6 hours as needed, not to exceed 400 mg per day. 1
Initial Dosing Recommendations
- For patients not requiring rapid onset of analgesic effect, a titration regimen is recommended to improve tolerability: start with lower doses and increase by 50 mg every 3 days as tolerated to reach 200 mg/day (50 mg four times daily) 1
- For elderly patients over 65 years old, dosing should be cautious, starting at the low end of the dosing range due to higher risk of adverse effects 1
- For elderly patients over 75 years old, total daily dose should not exceed 300 mg 1
- Extended-release formulations have a maximum daily dose of 300 mg 2, 3
Special Population Considerations
- For patients with renal impairment (creatinine clearance <30 mL/min), increase dosing interval to 12 hours with a maximum daily dose of 200 mg 1
- For patients with hepatic impairment (cirrhosis), the recommended dose is 50 mg every 12 hours 1
- Lower doses are recommended for older adults (75 years and older) to reduce the risk of seizures 2
- Hemodialysis patients can receive their regular dose on the day of dialysis, as only 7% of the dose is removed by hemodialysis 1
Mechanism of Action and Precautions
- Tramadol has a dual mechanism of action: weak mu-opioid receptor agonist and inhibition of norepinephrine and serotonin reuptake 2, 3
- Tramadol should be used with caution or avoided in patients taking serotonergic medications (e.g., SSRIs, TCAs, MAOIs) due to risk of serotonin syndrome 2, 4
- Common adverse effects include nausea, dizziness, drowsiness, constipation, and sweating 5
- Nausea is dose-dependent and more likely to appear if the initial dose is high; slow titration improves tolerability 6
Clinical Pearls
- Starting at the lowest possible dose and titrating upward results in fewer discontinuations and increased tolerability 1
- The onset of analgesic action occurs within 1 hour of oral administration 5
- Tramadol is approximately one-tenth as potent as morphine 2
- Unlike NSAIDs, tramadol does not aggravate hypertension, congestive heart failure, or cause peptic ulcer disease, making it potentially useful in elderly patients 5
- Compared to stronger opioids, tramadol has less respiratory depression and lower abuse potential 5
Formulation Considerations
- Immediate-release formulation: 50-100 mg every 4-6 hours, maximum 400 mg/day 2, 3, 1
- Sustained-release formulation: allows for twice-daily dosing with improved tolerability profile 7, 8
- Sustained-release capsules produce a smoother plasma concentration profile with more gradual absorption and lower peak concentrations compared to immediate-release formulations 7