Tramadol is a opioid like medication that is frequently used for moderate type pain. It is incredibly important to remember that because it has opioid activity, it can certainly lead to the risk of addiction and dependence. Here’s 2 other important tramadol pearls you need to remember with a case scenario.
A 74 year old male has been having increasing knee pain. Topical agents have not been effective, acetaminophen doesn’t work for him, and NSAIDs are not a good option as he is on warfarin and has kidney disease. His current medication list includes:
- Baby aspirin
- Fluoxetine
- Bupropion
- Omeprazole
- Biotin
- Tramadol
- Phenytoin
- Enalapril
- Nifedipine
In review of the medication list, it is obviously nice to have doses, but I try to teach the clinical thought process. In this patient I see he is on phenytoin. One of the tramadol pearls I wanted to mention today was to remember that tramadol can lower seizure threshold. This isn’t something we worry about too much in patients without a seizure history, but for those who do (or likely have seizures based on the phenytoin), we are very cautious in using tramadol.
Also of note in this patient is that he is on two medications for depression. I would like to further review this. One of the medications (bupropion) also can contribute to seizure issues. Tramadol and bupropion combination would be a very concerning one to me in a patient who likely has a history of seizures.
I would review the fluoxetine as well. Serotonin syndrome is extremely rare, but tramadol does have the potential to raise serotonergic effects. I would definitely want to know how high of a dose the fluoxetine is as well as assess how much of the tramadol is being used. If you’d like to learn more tramadol pearls, be sure to check out our recent podcast over at RealLifePharmacology.com.
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Nice points in here! I’d also add that tramadol is metabolized by 2D6 to an active metabolite. Fluoxetine and bupropion inhibit 2D6, so tramadol may have a limited pain effect in this patient. Also, I’d trash the asa unless he has a prosthetic mitral valve or recent MI 🙂