Tramadol Tricyclic antidepressants

Clinically important, potentially hazardous interactions with amitriptyline, amoxapine, amphetamines, bupropion, citalopram, clomipramine, cyproheptadine, desipramine, dextroamphetamine, dextromethorphan, diethylpropion, dopamine, doxepin, entacapone, ephedra, ephedrine, epinephrine, fluoxetine, fluvoxamine, ginseng, imipramine, levodopa, mazindol, meperidine, methamphetamine, nefazodone, nortriptyline, paroxetine, phendimetrazine, phentermine, phenylephrine, pizotifen, propoxyphene, protriptyline, pseudoephedrine, rizatriptan, sertraline, sibutramine, sumatriptan, sympathomimetics, tramadol, tricyclic antidepressants, trimipramine, tryptophan, venlafaxine, zolmitriptan... 

Dizziness, vertigo, nausea, vomiting, constipation, and lethargy are all relatively common adverse events. These effects are more pronounced for several days after initiation and following upward dose titration. Seizures have been reported rarely the risk is dose-related and appears to increase with concomitant use of antidepressants, such as tricyclic antidepressants or selective serotonin reuptake inhibitors. Tramadol should be avoided in patients receiving monoamine oxidase (MAO) inhibitors because tramadol inhibits the uptake of norepinephrine and serotonin. 

One of the main side-effects of opioid analgesics, such as codeine and tramadol, is constipation. Amitriptyline (tricyclic antidepressant) and orphenadrine tend to have antimuscarinic properties, resulting in side-effects such as constipation. Senna is a stimulant laxative indicated in constipation. 

Tramadol is an opioid analgesic and when given to patients who are also receiving imipramine (a tricyclic antidepressant), there is an increased risk of central nervous system toxicity. The risk of occurrence of sedation is increased. 

Fluoxetine and paroxetine inhibit cytochrome CYP P-450 2D6 and thus may affect metabolism of some opioids, e.g. codeine, 0) codone and tramadol, that are partly metabolised by CYP2D6, many antipsychotic drugs and tricyclic antidepressants. 

Clinically important, potentially hazardous interactions with alprazolam, amphetamines, astemizole, clarithromycin, clozapine, desipramine, dexibuprofen, dextroamphetamine, diethylpropion, droperidol, duloxetine, erythromycin, haloperidol, imipramine, isocarboxazid, linezolid, lithium, MAO inhibitors, mazindol, meperidine, methamphetamine, midazolam, moclobemide, nortriptyline, phendimetrazine, phenelzine, phentermine, phenylpropanolamine, phenytoin, pimozide, pseudoephedrine, selegiline, serotonin agonists, sibutramine, St John s wort, sumatriptan, sympathomimetics, tramadol, tranylcypromine, trazodone, tricyclic antidepressants, troleandomycin, tryptophan, zolmitriptan... 

In general, the concurrent use of most opioids and tricyclics is uneventful, although lethargy, sedation, and respiratory depression have been reported. Tramadol should be used with caution with tricyclic antidepressants because of the possible risk of seizures and the serotonin syndrome. Dextroproposyphene may cause moderate rises in the serum levels of amitriptyline and nortriptyUne, and methadone may moderately raise desipramine levels. The bioavailability and the degree of analgesia of oral morphine is increased by clomipramine, desipramine and possibly amitriptyline. 

Because the concurrent use of more than one serotonergic drug has rarely resulted in the serotonin syndrome , (p.9), the manufacturer advises caution if duloxetine is used with tricyclic antidepressants , (p.l240), or other antidepressants , (above), triptans, tramadol, and pethidine. ... 

The CSM in the UK has publicised 27 reports of convulsions and one of worsening epilepsy with tramadol, a reporting rate of 1 in 7000 patients. Some of the patients were given doses well in excess of those recommended, and some were taking SSRIs (5 patients) or tricyclic antidepressants , (p.l87), both of which are known to reduce the convulsive threshold. Similarly, of 124 seizure cases associated with tramadol reported to the FDA in the US, 20 included the concurrent use of SSRIs. ... 

Seizures have been reported in patients receiving tramadol. The risk of seizure is increased with doses of tramadol above the recommended range. Concomitant use of tramadol increases the seizure risk in patients taking tricyclic antidepressants, selective serotonin reuptake inhibitors, or other opioids. Tramadol may enhance the seizure risk in patients taking MAO inhibitors, neuroleptics, or other drugs that reduce the seizure threshold. Risk of convulsions may also increase in patients with epilepsy, those with a history of seizures, or in patients with a recognized risk for seizure (such as head trauma, metabolic disorders, alcohol and drug withdrawal, CNS infections). 

Tricyclic antidepressants and structurally similar drugs may block the antihypertensive action of guanethidine and may enhance the seizure risk in patients taking tramadol. 

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