Tramadol extended-release in the management of chronic pain
Chronic, noncancer pain such as that associated with
osteoarthritis of the hip and knee is typically managed according to American
College of Rheumatology guidelines. Patients unresponsive to first-line
treatment with acetaminophen receive nonsteroidal antiinflammatory drugs
(NSAIDs), including cyclooxygenase-2 (COX-2) inhibitors.
However, many patients
may have chronic pain that is refractory to these agents, or they may be at
risk for the gastrointestinal, renal, and cardiovascular complications
associated with their use. Tramadol, a mild opioid agonist and norepinephrine
and serotonin reuptake inhibitor, is recommended by current guidelines for the
treatment of moderate to moderately severe pain in patients who have not
responded to previous oral therapy, or in patients who have contraindications
to COX-2 inhibitors and nonselective NSAIDs.
An extended-release (ER) formulation of tramadol was approved by the US Food and Drug Administration in September 2005. In contrast with immediate-release (IR) tramadol, this ER formulation allows once-daily dosing, providing around-the-clock analgesia. In clinical studies, tramadol ER has demonstrated a lower incidence of adverse events than that reported for IR tramadol. Unlike nonselective NSAIDs and COX-2 inhibitors, tramadol ER is not associated with gastrointestinal, renal, or cardiovascular complications. Although tramadol is an opioid agonist, significant abuse has not been demonstrated after long-term therapy. It is concluded that tramadol ER has an efficacy and safety profile that warrants its early use for the management of chronic pain, either alone or in conjunction with nonselective NSAIDs and COX-2 inhibitors.
Interest and research into the mechanisms and treatment of neuropathic pain have increased during recent years, but current treatment is still far from satisfactory (Dworkin et al 2003; Attal et al 2006). The European Federation of Neurological Societies (EFNS) Task Force recently published guidelines for the pharmacological treatment of neuropathic pain (Attal et al 2006). However, no particular consideration is given as to how the recommendations are applicable to the elderly population. This paper will review the guidelines in relation to this population and evaluate the existing evidence relating to the use of these drugs in older persons.
Abstract: Prevention of postoperative pain in children is one of the most important objectives of the anesthesiologist. Opioids have been used as an analgesic for postoperative pain in children for many years. Tramadol has both opioid and monoaminergic agonist actions. The aim of the study was to determine if the analgesic potency and occurence of adverse effects of tramadol differ from pethidine when administered to children. A total of 110 healthy children, aged 2?12?years, scheduled for elective lower abdominal surgery were randomized to receive either pethidine 1?mg/kg (Group I, n?=?60) or tramadol 2?mg/kg (Group II, n?=?50) for postoperative pain after anesthesia induction. Pain intensity, adverse effects, heart rate, and systolic and diastolic blood pressure were recorded at regular intervals. The mean pain scores on postoperative 24?h were significantly greater with tramadol than with pethidine. Sedation scores, heart rate and systolic and diastolic blood pressure showed no significant differences betweeen the groups. We conclude that pethidine and tramadol are effective in providing analgesia in pediatric patients, but pethidine provided better postoperative analgesia than tramadol. Changes in blood pressure, heart rate and arterial oxygen saturation were minimal and were similar in both drugs.
The analgesic tramadol has many characteristics in common with the antidepressant venlafaxine. The drugs are structurally similar, share both serotonergic and noradrenergic properties, and undergo a similar metabolic fate. In this study, a patient, who developed significant depression following cessation of tramadol after several years of therapy, is described. Her depression was then treated with venlafaxine with excellent response. It appears that tramadol may have provided a prophylactic antidepressant effect in this patient. Because of its similarities to venlafaxine, tramadol may possibly exert a degree of antidepressant effect in certain patients, particularly those with chronic pain.
Tramadol hydrochloride is a racemic mixture of two enantiomers. It has analgesic activity suitable for mild to moderate pain, part of its analgesic activity being modulated via mu receptors. Adult studies have raised the question of increased electroencephalographic activity. The study examined the analgesic efficacy, respiratory effects, and behavior plus recovery-influencing properties of tramadol in the pediatric patient. Day-case dental extraction children, aged 4-7 years having 6 or more extractions, were studied. Tramadol drops, 3 mg/kg, plus oral midazolam, 0.5 mg/kg, were administered 30 minutes prior to a sevoflurane in N2O and O2 anesthetic. Forty children received this premedication treatment (T) and 10 entered a placebo control group (P), where no tramadol was administered. Entry was random, double blind, and parallel. Analgesic efficacy was measured using the Oucher face pain scale (OFPS), with responders scoring three or less. Respiration was measured by rate and oxygen saturation. Behavior and ease of mask induction were assessed on a 4-point scale. Recovery was measured with the Aldrete scale. Parameters were measured from 30 minute preanesthetic to 120 minute postanesthetic. Analgesic efficacy was shown, with an OFPS score of 11.42 (SD 18.66) (T) and 29.80 (SD 25.14) (P) (P .05). It is concluded that tramadol at 3 mg/kg has no clinical respiratory depressant effect and that behavior and recovery times are unaffected. Analgesic efficacy is demonstrated.
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