Episode #32: tramadol (Ultram) | Podcast Show Notes
tramadol (TRA ma dole)
Below will be links for the full Podcast and the Drug Card for tramadol along with a brief summary of various points on tramadol.
QUESTIONS:
- Which of the following are a black box warning for Ultram? Select all that apply.
- A). Contaminant use w/ benzodiazepines
- B). Contaminant use w/ CNS depressants
- C). Risk of medication errors
- D). Accidental ingestion
- E). Ultra-rapid metabolizer in children
- F). Only E
- When treating a 32 year old male patient for chronic pain, you notice a script was ordered for 100 mg q 4-6 hours as needed. Is there something wrong with this dosing? What is wrong and what could be done (if needed) to correct it?
- True or False. QT prolongation a concern in patients on tramadol.
- True or False. Tramadol is highly protein bound.
SUMMARY:
Tramadol can be used to treat and manage moderate to severe acute and chronic pain. It is also known as Ultram. An off label use is for Restless Leg Syndrome (RLS). When treating acute or chronic pain initiate 25-50 mg every 4-6 hours as needed with a max dosing range of 50-100 mg every 4-6 hours. The max dose per day is 400 mg. Tramadol acts on the mu-opioid receptor by blocking the ascending pain pathway. It alters the pain response and perception along with blocking reuptake of both serotonin and norepinephrine. Tramadol is extensively metabolized hepatically via the CYP3A4 and CYP2D6 pathway creating the metabolite M1. There is concern in children that are ultra-rapid metabolizers of CYP2D6 and use should be avoided in children. There are numerous black box warnings such as for addiction/abuse/misuse, risk of medication errors, accidental ingestion, and contaminant use w/ benzodiazepines or other CNS depressants. Monitor patients for level of pain relief and EKG and HR in patients with a family history of heart conditions.
ANSWERS:
- A, B, C, D, and E are all correct. F is not correct because it doesn’t include A-D.
- Yes there is an issue. Although part of the dosing regimen is within range some of the range exceeds the daily max dose of 400 mg/day. If the patient is using 100 mg every 6 hours then they are at the max of 400 mg/day (which is safe) but if they use 100 mg every 4 hour then they end up at 600 mg/day which is above the daily max. To avoid exceeding the daily max “prn” should be added along with a “max dose per day.”
- True. Among others QT prolongation is a concern.
- False. Tramadol is poorly protein bound with ~20% in the plasma.
PDF of Drug Card: tramadol
