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Opioid Analgesic (Weak) Pregnancy: Avoid in pregnancy; neonatal withdrawal possible

Tramadol

Brand names: Zydol, Tramacet (combination)

Adult dose

Dose: 50-100 mg every 4-6 hours
Route: Oral / IV / IM
Frequency: Every 4-6 hours
Max: 400 mg/day (300 mg/day in elderly)
Modified-release: 100-300 mg twice daily. Reduce dose and frequency in elderly

Paediatric dose

Dose: Seek specialist opinion N/A/kg
Route: Oral
Frequency: Seek specialist opinion
Max: Seek specialist opinion
Not recommended in children under 12 years; contraindicated under 18 for post-tonsillectomy pain (MHRA 2015)

Dose adjustments

Renal

Extend dosing interval to every 12 hours if eGFR under 30; avoid modified-release in severe renal impairment

Hepatic

Reduce dose in hepatic impairment; avoid in severe disease

Paediatric weight-based calculator

Not recommended in children under 12 years; contraindicated under 18 for post-tonsillectomy pain (MHRA 2015)

Clinical pearls

  • Beers Criteria 2023 and STOPP v3: Tramadol is potentially inappropriate in elderly — risk of falls, confusion, seizures, hyponatraemia, and serotonin syndrome
  • Converted to active metabolite (O-desmethyltramadol) by CYP2D6 — CYP2D6 poor metabolisers get less analgesia; ultra-rapid metabolisers get excessive opioid effect
  • Seizure threshold lowered — avoid in patients with epilepsy or on drugs that lower seizure threshold
  • Serotonin syndrome risk when combined with SSRIs (common in elderly with depression and pain comorbidity) — educate patients and prescribers
  • Controlled Drug: Schedule 3 in UK (since 2014) — requires prescription handwriting requirements no longer applicable for Schedule 3 in England

Contraindications

  • Concurrent MAOI use or within 14 days
  • Uncontrolled epilepsy
  • Acute intoxication with CNS depressants
  • Severe respiratory depression

Side effects

  • Nausea and vomiting (very common)
  • Dizziness and confusion (elderly particularly susceptible)
  • Constipation
  • Seizures (lowers seizure threshold)
  • Serotonin syndrome (with SSRIs/SNRIs/MAOIs)
  • Dependence
  • Hypoglycaemia

Interactions

  • SSRIs / SNRIs / MAOIs (serotonin syndrome — potentially fatal)
  • Tricyclic antidepressants (seizure risk, serotonin syndrome)
  • Carbamazepine (reduces tramadol efficacy via CYP3A4 induction)
  • Warfarin (enhanced anticoagulant effect)

Monitoring

  • Pain scores
  • CNS effects (confusion, sedation)
  • Signs of serotonin syndrome
  • Seizure activity

Reference: BNFc; BNF 90; AGS Beers Criteria 2023; STOPP/START v3; MHRA 2015 (tramadol in children). Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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