Tramal ® is a drug from the group of opioids. Opioids are among the strong painkillers, whereby a distinction is made within the opioids between low potency and high potency active ingredients. Low potency drugs such as tramadol can be used to treat moderate to severe pain, while high potency drugs such as fentanyl are reserved for the treatment of very severe pain. The World Health Organization (WHO) has set up a phased scheme that deals with pain therapy. At level 2, low-potency opioids, optionally in combination with Level 1 painkillers, ie non-steroidal anti-inflammatory drugs (NSAIDs) such as diclofenac or indomethacin, as well as paracetamol and metamizol (Novalgin®) are administered at level 3 to high potency opioids. Tramal ® is one of the low potency opioids, compared to morphine, it has a 0.1-fold potency. Almost all opioids are subject to the Betäubungsmittelgesetzt (BtM), Tramadol offers this an exception. It is available in the form of tablets, hard capsules, suppositories, drops and solution for injection.
Unlike drugs from the widely used group of non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or diclofenac, opioids have relatively minor side effects on the organism. However, they can cause numerous side effects that can be distressing to the person concerned. Often there is nausea and vomiting, sweating, headache, dry mouth and dizziness. Rarely, there may be a dizziness, which leads in some patients to the fact that the ability to drive is restricted. Furthermore, skin symptoms such as rash or redness of the skin may occur, and constipation is also common. These are on the one hand tormenting for the patient, on the other hand also dangerous, as they can lead to intestinal obstruction. Therefore, patients who are treated for a long time with opioids, often in addition to a drug that stimulates the intestinal activity (Laxans). Rare side effects of the opioids are changes in mood in the sense of euphoria or dysphoria (increased irritability), difficulty urinating (voiding), hallucinations and states of confusion, muscle weakness, respiratory depression, seizures, slowing the heartbeat (bradycardia), increase in blood pressure (hypertension) and allergic reactions.
Before prescribing Tramal ®, the doctor should be informed about all medicines taken, including non-prescription drugs that may have been purchased at the drugstore and are considered to be purely herbal and "harmless" because interactions can also occur here. The suppressive effect of Tramal ® can be significantly increased with the simultaneous use of sleeping pills, antidepressants of the sedative type (for example mirtazapine) and other opioids and under the influence of alcohol. Also, methadone and similar drugs to treat withdrawal dependency in drug addiction and codein-containing cough drops may increase the sedative effect of opioids. In addition, the combination of the above drugs with Tramal ® increases the risk of respiratory depression to respiratory arrest. Tramal ® itself can lower the seizure threshold and thus increase the risk of a seizure, especially in patients with previous illness. If Tramal ® is combined with other drugs that lower the seizure threshold, this risk increases significantly. These include antipsychotics such as haloperidol and antidepressants such as amitriptyline.
Another risk with the combination therapy of antidepressants and Tramal ® is the triggering of a potentially life-threatening serotonin syndrome. This can lead to muscle twitching (myoclonus), tremor (tremor), fever, sweating, increase in heart rate (tachycardia) and blood pressure (hypertension) and impaired consciousness. In particular, antidepressants from the group of selective serotonin reuptake inhibitors ( SSRI ) such as citalopram and those from the group of MAO inhibitors such as moclobemide in combination with Tramal® significantly increase the risk of such a serotonin syndrome.
Many more information can be found in our topic: Serotonin Syndrome
In patients taking blood thinners from the group of vitamin K antagonists (coumarins) such as Marcumar® ( phenprocoumone ), a dose adjustment in the sense of a reduction may be necessary, since there is an even greater tendency to bleed in the therapy with Tramal ® This can be seen in the laboratory as a further drop in the Quick value or increase in the INR value. The anti-nausea drug ondansetron, a serotonin receptor antagonist, can inhibit the analgesic effects of tilidine, as can carbamazepine, which is used to treat epilepsy, mania, and neuropathic pain.
The single dose of Tramal ® drops can be 20-40 drops, often prescribed by the doctor 30 drops as a single dose. 20 drops of Tramal ® contain 50 mg tramadol. The daily maximum dose, as with the tablets and hard capsules, is 400 mg, corresponding to 160 drops. Accordingly, a maximum of 40 drops can be taken in the morning, at noon, in the evening and at night.
Tramal ® drops are used as well as tablets for the treatment of moderate to severe pain. They are thus used in stage 2 of the 3-step WHO pain therapy regimen and can be combined with WHO level 1 analgesics such as indomethacin, ibuprofen, paracetamol or metamizol (Novalgin®). A combination of low-potency opioids such as Tramal ® with high-potency opioids such as fentanyl should be avoided, as they have mutually inhibitory effects on each other in their analgesic action.
In acute intoxication with sleeping pills, alcohol, antidepressants or other drugs from the group of opioids as well as in an intoxication with heroin (belongs to the opioids) Tramal® should not be taken, as the depressant and respiratory depressive effects are significantly increased and to the breath - And can cause cardiac arrest.
In addition, Tramal ® should not be taken if treatment with MAO inhibitors is used to treat depression as it significantly increases the risk of serotonin syndrome. MAO inhibitors must be discontinued for at least 14 days prior to treatment with Tramal ® .
Concomitant therapy with Tramal ® and antidepressants from the group of selective serotonin reuptake inhibitors (SSRIs), such as citalopram or fluoxetine, poses a similar risk and combination therapy should therefore be performed under the strictest indications and with the utmost care and regular controls. Tramal ® should not be used in patients with epilepsy who are not well-off medicated as the risk of seizures is increased.
Other relative contraindications (intake of Tramal ® not absolutely contraindicated but with great caution) are impaired consciousness, disorders of breathing, conditions with increased intracranial pressure and a marked renal insufficiency or hepatic insufficiency. The use of Tramal ® in pregnancy and lactation is not absolutely contraindicated, single doses can be given relatively unscrupulously. Nevertheless, the indication should be weighed exactly. A longer-term therapy with Tramal ® during pregnancy and lactation should be avoided, as the child can get used to the drug, which may show with withdrawal symptoms after birth or during lactation. In Senium patients (over 75 years of age), Tramal® excretion may be prolonged and the dose may need to be adjusted to decrease it.
Tramal ® drops at a dose of 100 mg / ml (about 50 mg per 20 drops) are available in 10 ml, 20 ml, 50 ml and 100 ml packs. This cost 10 ml on private recipe 12.21 euros, 20 ml 13.53 euros, 50 ml 18.04 euros and 100 ml 26.30 euros. When presenting a cash receipt, only the prescription fees of 5 € are incurred.