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

Maximum Daily Dose of Tramadol

The maximum recommended dose of tramadol is 400 mg per day for immediate-release formulations and 300 mg per day for extended-release formulations. 1, 2

Standard Dosing for Immediate-Release Tramadol

For most adults with moderate to moderately severe pain, tramadol immediate-release should be dosed at 50-100 mg every 4-6 hours, not exceeding 400 mg per day. 1, 2

Titration Strategy for Improved Tolerability

• Start with 50 mg once or twice daily, then increase by 50-100 mg every 3-7 days as tolerated, up to a maximum of 400 mg/day in divided doses. 2
• This gradual titration approach significantly reduces discontinuations and improves tolerability compared to starting at higher doses. 1
• Nausea occurs early in treatment and is dose-dependent, making slow titration particularly important for reducing this common adverse effect. 3

Rapid-Onset Dosing (When Benefits Outweigh Risks)

• For patients requiring rapid pain relief where benefits outweigh the risk of adverse events, tramadol 50-100 mg can be administered every 4-6 hours as needed, not to exceed 400 mg per day. 1

Extended-Release Formulations

Extended-release tramadol has a lower maximum daily dose of 300 mg per day. 2

• Tramadol SR capsules are dosed at 100 mg twice daily for most patients. 4
• The SR formulation produces smoother plasma concentrations with less fluctuation and lower peak levels compared to immediate-release, potentially improving tolerability. 4

Special Population Dose Adjustments

Elderly Patients

• For patients over 75 years old, the total daily dose should not exceed 300 mg per day. 1, 2
• For elderly patients over 65 years, start at the low end of the dosing range due to decreased hepatic, renal, or cardiac function. 1, 2

Renal Impairment

• For creatinine clearance <30 mL/min, increase the dosing interval to every 12 hours with a maximum daily dose of 200 mg. 1, 2
• Only 7% of tramadol is removed by hemodialysis, so dialysis patients can receive their regular dose on dialysis days. 1

Hepatic Impairment

• For patients with cirrhosis, the recommended dose is 50 mg every 12 hours. 1, 2

Critical Safety Considerations

Seizure Risk

• The risk of seizures increases with high doses or in predisposed patients. 2
• This makes adherence to maximum dosing limits particularly important for patient safety.

Serotonin Syndrome Risk

• Tramadol should be used with caution or avoided in patients taking serotonergic medications (SSRIs, MAOIs, tricyclic antidepressants) due to risk of serotonin syndrome. 2, 5
• Do not administer tramadol to patients receiving monoamine oxidase inhibitors. 5

Relative Potency

• Tramadol is approximately 0.1-0.2 times as potent as oral morphine, making it suitable for moderate pain but insufficient for severe pain. 2, 5

Common Pitfall to Avoid

Allow at least 4 weeks at therapeutic doses before deeming tramadol ineffective. 2 Many clinicians prematurely discontinue tramadol without giving adequate time for assessment of efficacy at appropriate doses.