Symptoms
Symptoms of overdosage are typical of other opioid analgesics, and include miosis, vomiting, circulatory collapse, sedation and coma, seizures and respiratory depression. In severe cases tramadol overdose may result in a fatal outcome.
Management
A patent airway must be maintained. The pure opioid antagonists such as naloxone are specific antidotes against symptoms from opioid overdose induced by tramadol, though it will not antagonize tramadol's inhibitory effects on MAO reuptake or serotonin releasing effects. Other supportive measures should be employed as needed. Naloxone should be used to reverse respiratory depression; fits can be controlled with diazepam. In case of oral intake of overdose, consider activated charcoal if the patient presents within one hour of ingestion of tramadol, provided the patient's airway can be protected.
Although it may seem reasonable to assume that later administration of activated charcoal may be beneficial for prolonged-release preparations and drugs that slow gastric emptying, there is no clinical trial evidence to support this.
Tramadol is minimally eliminated from the serum by haemodialysis or haemofiltration. Therefore treatment of acute intoxication with tramadol with haemodialysis or haemofiltration alone is not suitable for detoxification.
3 years.
Tramadol must not be used for narcotic withdrawal treatment
Not applicable.
Tablet core
Hydrogenated vegetable oil
Talc
Magnesium stearate
Film coat
Lactose monohydrate
Hypromellose (E464)
Titanium dioxide (E171)
Macrogol 4000
Iron oxide yellow (E172)
Iron oxide black (E172)
Zytram SR 75 mg: Indigo carmine aluminium lake (E132)
Zytram SR 150 mg: Iron oxide red (E172)
Zytram SR 200 mg: Iron oxide red (E172)
Zytram SR 75 mg:
Prolonged release tablet.
Grey, film coated, round tablets approximately 7 mm in diameter marked TBD on one side and 75 on the other.
Zytram SR 100 mg:
Prolonged release tablet.
White, film coated, round tablets approximately 8 mm in diameter, marked TBD on one side and 100 on the other.
Zytram SR 150 mg:
Prolonged release tablet.
Beige, film coated, round tablets approximately 9.5 mm in diameter, marked TBD on one side and 150 on the other.
Zytram SR 200 mg:
Prolonged release tablet.
Orange, film coated, round tablets approximately 10 mm in diameter, marked TBD on one side and 200 on the other.
The following frequency categories form the basis for classification of the undesirable effects:
Very common (>1/10)>
Common (>1/100 to <1/10)>
Uncommon (>1/1,000 to <1/100)>
Rare (>1/10,000 to <1/1,000)>
Very rare (<1/10,000)
Not known (cannot be estimated from the available data)
|
Very Common |
Common |
Uncommon |
Rare |
Very Rare |
Not known | |
|
Immune system disorders |
Hyper-sensitivity Anaphylactic and anaphylactoid responses | |||||
|
Metabolism and nutrition disorders |
Decreased appetite |
Hypoglycaemia | ||||
|
Psychiatric disorders |
Hallucinations Nightmare Mood altered Euphoric moodDysphoria Decreased activity Illusion Confusional state Drug dependence | |||||
|
Nervous system disorders |
Dizziness |
Somnolence |
Headache |
Paraesthesia Psychomotor hyperactivity Cognitive disorder Sensory disturbance Judgment impaired Convulsions | ||
|
Eye disorders |
Blurred vision | |||||
|
Cardiac disorders |
Palpitations Tachycardia |
Bradycardia | ||||
|
Vascular disorders |
Orthostatic hypotension Hypotension Circulatory collapse |
Hypertension Flushing | ||||
|
Respiratory, thoracic and mediastinal disorders |
Dyspnoea Worsening of asthma Respiratory depression Bronchospasm Wheezing | |||||
|
Gastro-intestinal disorders |
Nausea |
Vomiting Dry mouth |
Retching Constipation Abdominal discomfort |
Diarrhoea | ||
|
Hepatobiliary disorders |
Hepatic enzyme increased | |||||
|
Skin and subcutaneous tissue disorders |
Hyperhi-drosis |
Pruritus Rash Urticaria |
Angioedema | |||
|
Musculoskeletal and connective tissue disorders |
Muscular weakness | |||||
|
Renal and urinary disorders |
Micturition disorder Dysuria Urinary retention | |||||
|
General disorders and administration site conditions |
Drug withdrawal syndrome which may include: - agitation; - anxiety - nervousness - insomnia - hyperkinesia - termor; Gastrointestinal symptoms |
Asthenia |
As these tablets are made using an insoluble matrix from which the active ingredient is gradually released, the patient may notice the matrix in their faeces.
Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard.
Preclinical data reveal no special hazard for humans based on conventional studies of safety pharmacology, repeated dose toxicity, genotoxicity or carcinogenic potential.
Reproductive and developmental toxicity
No effects of tramadol have been observed on male or female fertility in rats. Fetal malformations occurred in a rat developmental study in the presence of maternal toxicity and mortality. No developmental effects were observed in the rat at 20 mg/kg/day when plasma concentrations of tramadol and O-desmethyltramadol were 2.3x and 2.2x the estimated mean clinical Cmax and 1.1x and 1.5x the estimated mean clinical AUCt at the maximum recommended dose of ZYTRAM SR 200 mg twice daily. When female rats were treated during gestation and lactation there was increased pup mortality and decreased body weights during lactation for the offspring at maternally toxic dose levels of 60 mg/kg/day.
Treatment of moderate to severe pain.
These tablets are indicated in adults and adolescents aged 12 years and above.
Pharmacotherapeutic group: Analgesic, Other opioids. ATC code: N02A X02
Mechanism of action
Tramadol is a centrally acting analgesic It is a non selective pure agonist at mu, delta and kappa opioid receptors with a higher affinity for the mu receptor. Other mechanisms that may contribute to its analgesic effect are inhibition of neuronal re-uptake of noradrenaline and an increased serotonin release.
Paediatric population
Effects of enteral and parenteral administration of tramadol have been investigated in clinical trials involving more than 2000 paediatric patients ranging in age from neonate to 17 years of age. The indications for pain treatment studied in those trials included pain after surgery (mainly abdominal), after surgical tooth extractions, due to fractures, burns and traumas as well as other painful conditions likely to require analgesic treatment for at least 7 days.
At single doses of up to 2 mg/kg or multiple doses of up to 8 mg/kg per day (to a maximum of 400 mg per day) efficacy of tramadol was found to be superior to placebo, and superior or equal to paracetamol, nalbuphine, pethidine or low dose morphine. The conducted trials confirmed the efficacy of tramadol. The safety profile of tramadol was similar in adult and paediatric patients older than 1 year.
Absorption
Following oral administration of a single dose, tramadol is almost completely absorbed and the absolute bioavailability is approximately 70% following administration of a single dose. Tramadol is metabolised to O desmethyltramadol, which has been shown to have analgesic activity in rodents. The elimination half life of tramadol is around 6 hours, although this is extended to around 12 hours following prolonged absorption from the ZYTRAM SR tablet.
Biotransformation
Following administration of one ZYTRAM SR tablet 75 mg in the fasting state, a mean peak plasma concentration (Cmax) of 80 ng.ml-1 was attained. This was associated with a median tmax of 5 hours (range 3-7 hours). In the presence of food, the availability and controlled release properties of ZYTRAM SR tablets were maintained, with no evidence of dose-dumping.
Elimination
A single dose-proportionality study has confirmed a linear pharmacokinetic response (in relation to tramadol and O-desmethyltramadol) following administration of the 75 mg, 100 mg, 150 mg and 200 mg tablets. A steady state study has confirmed the dose adjusted bioequivalence of the 75 mg, 100 mg and 150 mg tablets administered twice-daily.
The pharmacokinetics of tramadol are non-linear. Faster-releasing formulations are associated with an accumulation of the drug substance which is greater than would be anticipated from single dose data, a consequence of a saturated first-pass effect. The controlled delivery of tramadol from the range of ZYTRAM SR tablets minimises the non-linearity associated with faster-releasing preparations and consequently, single dose and steady state studies have demonstrated that, when compared with immediate release preparations, the mean availability of tramadol from the ZYTRAM SR tablet 75 mg was approximately 82%. On this basis it is recommended that patients receiving immediate release tramadol should be transferred initially to the nearest daily dose of ZYTRAM SR tablets. It may be necessary to titrate the dose thereafter. The more predictable plasma concentrations may lead to a more manageable dose titration process.
Paediatric population
The pharmacokinetics of tramadol and O-desmethyltramadol after single-dose and multiple-dose oral administration to subjects aged 1 year to 16 years were found to be generally similar to those in adults when adjusting for dose by body weight, but with a higher between-subject variability in children aged 8 years and below.
In children below 1 year of age, the pharmacokinetics of tramadol and O-desmethyltramadol have been investigated, but have not been fully characterized. Information from studies including this age group indicates that the formation rate of O-desmethyltramadol via CYP2D6 increases continuously in neonates, and adult levels of CYP2D6 activity are assumed to be reached at about 1 year of age. In addition, immature glucuronidation systems and immature renal function may result in slow elimination and accumulation of O-desmethyltramadol in children under 1 year of age.
21/12/2017
Qdem Pharmaceuticals Limited
Cambridge Science Park
Milton Road
Cambridge CB4 0AB
Do not store above 30°C.
1) PVC blisters with aluminium backing foil (containing 7, 14, 28, 30, 56 or 60 tablets).
2) Polypropylene containers with polyethylene lids (containing 7, 14, 28, 30 & 56 tablets).
Not all pack sizes may be marketed.
PL 40431/0035, 0036, 0037, 0038
Pregnancy
There are no adequate data from the use of tramadol in pregnant women. Animal studies have shown reproductive toxicity, but not teratogenic effects. Tramadol crosses the placental barrier and chronic use during pregnancy can cause withdrawal symptoms in the new-born baby. Therefore, it should not be used during pregnancy.
Tramadol administered before or during birth does not affect uterine contractility. In neonates it may induce changes in respiratory rate which are not usually clinically relevant.
Breastfeeding
During lactation very small amounts of tramadol and its metabolites (approximately 0.1% of an intravenous dose) are found in human breast milk. Therefore tramadol should not be administered during breast feeding.
The patient may develop tolerance to the medicinal product with chronic use and require progressively higher doses to maintain pain control. Prolonged use may lead to physical dependence and a withdrawal syndrome may occur upon abrupt cessation of therapy. When a patient no longer requires therapy with tramadol, it may be advisable to taper the dose gradually to prevent symptoms of drug withdrawal syndrome.
There is potential for abuse and development of psychological dependence to opioid analgesics, including tramadol , thereforethe clinical need for continued analgesic treatment should be reviewed regularly. Treatment should be for short periods and under strict medical supervision. These tablets should be used with particular care in patients with a history of alcohol and drug abuse.
Tramadol is not suitable as a substitute in opioid-dependent patients. Although it is an opioid agonist, tramadol cannot suppress morphine withdrawal symptoms.
Convulsions have been reported at therapeutic doses and the risk may be increased at doses exceeding the usual upper daily dose limit. Patients with a history of epilepsy or those susceptible to seizures should only be treated with tramadol if there are compelling reasons. The risk of convulsions may increase in patients taking tramadol and concomitant medication that can lower the seizure threshold.. Tramadol should therefore be used with caution in patients prone to convulsive disorders.
Tramadol should be used with caution in patients with head injury, increased intracranial pressure, severe impairment of hepatic and renal function and in patients in shock.
Care should be taken when treating patients with respiratory depression, or if concomitant CNS depressant drugs are being administered, as the possibility of respiratory depression cannot be excluded in these situations. At therapeutic doses respiratory depression has infrequently been reported.
This medicinal product contains lactose. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency of glucose-galactose malabsorption should not take this medicinal product.
Tramadol may cause drowsiness, blurred vision and dizziness which may be enhanced by alcohol or other CNS depressants. If affected, the patient should not drive or operate machinery.
This medicine can impair cognitive function and can affect a patient's ability to drive safely. This class of medicine is in the list of drugs included in regulations under 5a of the Road Traffic Act 1988. When prescribing this medicine, patients should be told:
- The medicine is likely to affect your ability to drive.
- Do not drive until you know how the medicine affects you.
- It is an offence to drive while you have this medicine in your body over a specified limit unless you have a defence (called the 'statutory defence').
- This defence applies when:
o The medicine has been prescribed to treat a medical or dental problem; and
o You have taken it according to the instructions given by the prescriber and in the information provided with the medicine.
- Please note that it is still an offence to drive if you are unfit because of the medicine (i.e. your ability to drive is being affected).
Details regarding a new driving offence concerning driving after drugs have been taken in the UK may be found here: https://www.gov.uk/drug-driving-law.
Route of administration
Oral use
Posology
The dose should be adjusted to the intensity of the pain and the sensitivity of the individual patient. The lowest effective dose for analgesia should generally be selected. The correct dosage per individual patient is that which controls the pain with no or tolerable side effects for a full 12 hours. Patients transferring from immediate release tramadol preparations should have their total daily dose calculated, and start on the nearest dose in the ZYTRAM SR range. It is recommended that patients are slowly titrated to higher doses to minimise transient side effects. The need for continued treatment should be assessed at regular intervals as withdrawal symptoms and dependence have been reported.. A total daily dose of 400 mg should not be exceeded except in special clinical circumstances.
Adults and children over 12 years:
The usual initial dose is one 75 mg tablet twice daily. If pain relief is not achieved, the dosage should be titrated upwards until pain relief is achieved.
Geriatric patients:
A dose adjustment is not usually necessary in patients up to 75 years without clinically manifest hepatic or renal insufficiency. In elderly patients over 75 years elimination may be prolonged. Therefore, if necessary the dosage interval is to be extended according to the patient's requirements.
Renal insufficiency/dialysis and hepatic impairment:
In patients with renal and/or hepatic insufficiency the elimination of tramadol is delayed. In these patients prolongation of the dosage intervals should be carefully considered according to the patient's requirements.
As tramadol is only removed very slowly by haemodialysis or by haemofiltration, post-dialysis administration to maintain analgesia is not usually necessary.
Paediatric population under 12 years of age:
ZYTRAM SR has not been studied in children. The safety and efficacy of ZYTRAM SR has not been established and the product should not be used in children.
Method of administration
These tablets should be taken at 12-hourly intervals and must be swallowed whole and not broken, crushed or chewed.
No special requirement.
28/11/2007
Concurrent administration of tramadol with other centrally acting drugs, including alcohol, may potentiate CNS depressant effects.
Tramadol can induce convulsions and increase the potential for selective serotonin re-uptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants, antipsychotics and other seizure threshold-lowering medicinal products (such as bupropion, mirtazapine, tetrahydrocannabinol) to cause convulsions.
Concomitant therapeutic use of tramadol and serotonergic drugs, such as selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), MAO inhibitors , tricyclic antidepressants and mirtazapine may cause serotonin toxicity. Serotonin syndrome is likely when one of the following is observed:
- Spontaneous clonus
- Inducible or ocular clonus with agitation or diaphoresis
- Tremor and hyperreflexia
- Hypertonia and body temperature > 38°C and inducible or ocular clonus.
Withdrawal of the serotonergic drugs usually brings about a rapid improvement. Treatment depends on the type and severity of the symptoms.
Simultaneous treatment with carbamazepine may shorten the analgesic effect as a result of a reduction in serum levels of tramadol and its active metabolite.
Co-administration with cimetidine is associated with a small prolongation of the half-life of tramadol, but this is not clinically relevant.
Co-administered ritonavir may increase serum concentrations of tramadol resulting in tramadol toxicity.
Digoxin toxicity has occurred rarely during co-administration of digoxin and tramadol.
Other morphine derivatives (including anti-tussives, substitution treatments), benzodiazepines, barbiturates: Increased risk of respiratory depression, that may be fatal in overdosage.
Mixed agonists/antagonists (eg buprenorphine, nalbuphine, pentazocine); The analgesic effect of tramadol, which is a pure agonist, may be reduced and a withdrawal syndrome may occur.
There have been isolated reports of interaction with coumarin anticoagulants resulting in an increased INR and so care should be taken when commencing treatment with tramadol in patients on anticoagulants.
The analgesic effect of tramadol is in part mediated by inhibition of the re-uptake of norepinephrine and enhancement of the release of serotonin (5-HT). In studies the pre- or postoperative application of the antiemetic 5-HT3 antagonist ondansetron increased the requirements of tramadol in patients with postoperative pain.
