Maximum Daily Dose of Tramadol
The maximum daily dose of tramadol for adults is 400 mg/day for immediate-release formulations and 300 mg/day for extended-release formulations. 1, 2
Standard Dosing for Adults
Special Population Dose Reductions
Elderly Patients
- For patients over 75 years: Maximum 300 mg/day 1, 3
- Start at the low end of dosing range (25 mg every 12 hours initially), with slower titration over days to weeks 3
Renal Impairment
- For creatinine clearance <30 mL/min: Maximum 200 mg/day 1, 2
- Increase dosing interval to every 12 hours 1, 2
- Hemodialysis patients can receive regular dose on dialysis day since only 7% is removed by dialysis 1
Hepatic Impairment
- For cirrhosis: 50 mg every 12 hours (100 mg/day maximum) 1, 3
- Bioavailability increases 2-3 fold in cirrhotic patients 3
Critical Safety Considerations
- Tramadol has dual mechanism: weak mu-opioid receptor agonist plus inhibition of norepinephrine and serotonin reuptake 2, 3
- Risk of serotonin syndrome when combined with SSRIs, SNRIs, TCAs, or MAOIs - use with extreme caution or avoid 2, 3
- Seizure risk increases at high doses or in predisposed patients 2, 3
- Tramadol is approximately 0.1-0.2 times as potent as oral morphine, making it suitable only for moderate pain 2, 3
Common Pitfall to Avoid
- Do not exceed 400 mg/day for immediate-release formulations - this is the absolute maximum regardless of pain severity 1, 2. If pain remains inadequately controlled at 400 mg/day, transition to a stronger opioid (morphine 20-40 mg/day or oxycodone 20 mg/day) rather than exceeding tramadol's maximum dose 3