Does Tramadol Cause Vomiting?
Yes, tramadol commonly causes vomiting, with FDA-reported incidence rates of 9% within 7 days, 13% within 30 days, and 17% within 90 days of treatment in chronic pain trials. 1
Incidence and Time Course of Vomiting
- Vomiting is one of the most frequent adverse effects of tramadol, occurring alongside nausea as the primary gastrointestinal complications. 1
- In chronic nonmalignant pain trials, the cumulative incidence of vomiting increases progressively: 9% by day 7,13% by day 30, and 17% by day 90. 1
- Nausea occurs even more frequently than vomiting, with rates of 24% at 7 days, 34% at 30 days, and 40% at 90 days. 1
- In cancer pain studies, patients on tramadol experienced "much more frequent adverse effects such as nausea, vomiting and constipation" compared to placebo. 2
Mechanism and Risk Factors
- Tramadol's dual mechanism of action—weak mu-opioid receptor agonism combined with serotonin and norepinephrine reuptake inhibition—contributes to its gastrointestinal side effects. 3, 4
- The serotonergic activity specifically increases the risk of nausea and vomiting, particularly when combined with other serotonergic medications (SSRIs, SNRIs, TCAs, MAOIs). 1
- Adverse effects, particularly nausea and vomiting, are dose-dependent and considerably more likely with high loading doses. 5
Critical Strategies to Minimize Vomiting
Slower titration rates dramatically reduce the incidence of vomiting and treatment discontinuation. 6
- A study comparing titration schedules found that 13-day and 16-day titration schedules resulted in significantly fewer discontinuations due to nausea/vomiting (22%) compared to a 10-day schedule (P=0.008 and P=0.006, respectively). 6
- The rate of titration, rather than the target dose, is the major determinant of tolerability. 6
- For intravenous administration, slower injection over 3 minutes significantly reduces the incidence of nausea and vomiting compared to 1-minute administration. 7
Practical Dosing Recommendations to Reduce Vomiting
- Start tramadol at 25-50 mg once or twice daily, then increase by 50 mg every 3-7 days as tolerated, rather than starting at higher doses. 3
- For elderly patients or those with renal impairment, begin at 25 mg every 12 hours and titrate even more slowly over days to weeks. 4, 8
- Reduction of the loading dose during the first days of treatment is an important factor in improving tolerability. 5
Comparative Context
- In randomized controlled trials comparing tramadol to hydrocodone/paracetamol, patients treated with tramadol had a significantly higher incidence of nausea, vomiting, vertigo, anorexia and asthenia. 2
- When compared to codeine and hydrocodone, tramadol produced a significantly higher percentage of side effects overall. 2
- The incidence of nausea and vomiting varies by route and setting: postoperative studies show higher rates (17.8% and 7.0% with intramuscular administration) compared to outpatient settings (4.2% and 0.5% in postmarketing surveillance). 9
Clinical Pitfalls to Avoid
- Do not start at standard doses (50-100 mg every 4-6 hours) in opioid-naïve patients, as this dramatically increases the risk of vomiting and early discontinuation. 6, 5
- Do not rapidly escalate doses—allow at least 3-7 days between dose increases. 3
- Avoid combining tramadol with serotonergic medications when possible, as this increases both nausea/vomiting and the risk of serotonin syndrome. 1, 4
- When administering intravenously, inject slowly over at least 3 minutes rather than rapid bolus to minimize acute nausea and vomiting. 7