January 23, 2018

Tramadol, Are You Up to Date?

There has been a lot of talk in the clinics I visit lately due to Tramadol becoming a controlled drug.  However, most of you have already been treating it as such.  The bigger questions asked of me is how to use it and at what dosage.  Tramadol is not as bioavailable in dogs as it is in humans.  This is why it is best used in conjunction with an NSAID versus being used alone for pain. 1*

TramaIt acts as a full mu agonist and has some NMDA activity as well.  It is best used as a way to wean off of injectable opiods that are also full mu agonists, like hydromorphone, oxymorphone or fentanyl.  Tramadol should not be given at the same time as Buprenex.  Buprenex is a partial mu agonist, but has a stronger affinity for the receptor.  Giving tramadol and Buprenex together will counteract the possible pain relief of tramadol.  You may still have a little NMDA activity, but this is controversial as best. These guidelines make concomitant usage of these two drugs a major contraindication. 2*

How about your dosage?  Are you sure you are giving it enough when you are using it?  Current recommendation are to start at 5mg/kg for dogs, at least twice a day.  More realistically every six hours at this dosage may have pain relief.  If you are using 2mg/kg it has to be given every four hours to approach therapeutic levels of pain relief in the blood stream.  There is also evidence that the pain relief may wean off after 7-10 days of therapy.  We are unclear if chronic, daily usage may need wash-out periods to maintain good production of the active metabolite O-desmethlytramadol in dogs.  3* 

Tramadol is a great drug and has definitely helped our postoperative care of our patients.  It has a wide range of safety, with very few side effects in dogs.  It should be given with other pain medications for the best postoperative pain relief.  It should also start at 5mg/kg BID, with acute surgical patients using it more frequently for the first few days.  If you are using Buprenex before tramadol, stagger your oral tramadol to at least six hours after your last Buprenex injection.  Even when waiting to start the tramadol, the first dosage after your Buprenex may not be fully efficacious.  The other options for strong orthopedic surgery pain relief, would be to use full mu agonists as your injectable opiods, or consider the new topical fentanyl formulation.

1*

J Am Vet Med Assoc. 2013 Jul 15;243(2):225-31. doi: 10.2460/javma.243.2.225.

Comparison of the analgesic efficacy of perioperative firocoxib and tramadol administration in dogs undergoing tibial plateau leveling osteotomy.
Davila D1, Keeshen TP, Evans RB, Conzemius MG.

2*

GENERALLY AVOID: Mixed opioid agonist-antagonist analgesics such as buprenorphine, butorphanol, nalbuphine, and pentazocine may theoretically decrease the analgesic effects of tramadol or cause withdrawal symptoms in patients who have been taking tramadol.

MANAGEMENT: Concomitant use of tramadol and other opioids, including mixed agonist/antagonist analgesics, should be avoided in general. Tramadol should not be used in opioid-dependent patients, and use in patients who are chronically on opioids is also not recommended. Tramadol is contraindicated in patients with acute opioid intoxication. Tramadol dosage should be reduced if it must be used in patients receiving opioids. Patients should be monitored for development of seizures and CNS and respiratory depression.

3*

J Vet Pharmacol Ther. 2004 Aug;27(4):239-46.

Pharmacokinetics of tramadol and the metabolite O-desmethyltramadol in dogs.

KuKanich B1, Papich MG.

Vet Res Commun. 2009 Sep;33 Suppl 1:189-92. doi: 10.1007/s11259-009-9278-4.

Biopharmaceutical profile of tramadol in the dog.

Giorgi M1, Del Carlo S, Saccomanni G, Łebkowska-Wieruszewska B, Turini V, Kowalski C.