1. Name Of The Medicinal Product
ZYDOL XL 300 mg tablets.
2. Qualitative And Quantitative Composition
Tablets containing tramadol hydrochloride 300 mg.
For excipients, see 6.1
3. Pharmaceutical Form
Prolonged release, white, film coated tablets, marked T 300.
4. Clinical Particulars
4.1 Therapeutic Indications
Treatment of moderate to severe pain.
4.2 Posology And Method Of Administration
ZYDOL XL tablets should be taken at 24-hourly intervals and must be swallowed whole and not chewed.
As with all analgesic drugs, the dose of tramadol should be adjusted according to the severity of the pain and the clinical response of the individual patient. The correct dosage for any individual patient is that which controls the pain with no or tolerable side effects for a full 24 hours. Patients transferring from immediate release tramadol preparations should have their total daily dose calculated, and start on the nearest dose in the ZYDOL XL range. It is recommended that patients are slowly titrated to higher doses to minimise transient side effects. The need for continued treatment should be assessed at regular intervals as withdrawal symptoms and dependence have been reported. (See Section 4.4 Special Warnings and Precautions for Use).A total daily dose of 400 mg should not be exceeded except in special clinical circumstances.
Adults and children over 12 years: The usual initial dose is one 150 mg tablet daily. If pain relief is not achieved, the dosage should be titrated upwards until pain relief is achieved.
Elderly and patients with renal or hepatic impairment: Dosing as for adults. The elimination half-life of tramadol may be prolonged in patients over 75 years. A starting dose of 150 mg daily is recommended. Dose titration upwards should be carefully monitored.
Patients with renal or hepatic insufficiency:
The elimination half-life of tramadol may be prolonged in these patient populations. A starting dose of 150 mg daily is recommended. Dose titration upwards should be carefully monitored. Tramadol is not recommended for patients with severe renal impairment and/or severe hepatic impairment.
As tramadol is only removed very slowly by haemodialysis or by haemofiltration, post-dialysis administration to maintain analgesia is not usually necessary.
Children under 12 years: ZYDOL XL has not been studied in children. Safety and efficacy of ZYDOL XL have not been established and the product should not be used in children.
4.3 Contraindications
Hypersensitivity to tramadol or to any of the excipients; acute intoxication with alcohol, hypnotics, centrally acting analgesics, opioids or psychotropic drugs. Tramadol should not be administered to patients who are receiving monoamine oxidase inhibitors or within two weeks of their withdrawal.
Tramadol must not be used for narcotic withdrawal treatment.
4.4 Special Warnings And Precautions For Use
Warnings
At therapeutic doses withdrawal symptoms have been reported at a frequency of 1 in 8,000. Reports of dependence and abuse have been less frequent. Because of this potential the clinical need for continued analgesic treatment should be reviewed regularly.
In patients with a tendency to drug abuse or dependence, treatment should be for short periods and under strict medical supervision.
Tramadol is not suitable as a substitute in opioid-dependent patients. Although it is an opioid agonist, tramadol cannot suppress morphine withdrawal symptoms.
Precautions
Convulsions have been reported at therapeutic doses and the risk may be increased at doses exceeding the usual upper daily dose limit. Patients with a history of epilepsy or those susceptible to seizures should only be treated with tramadol if there are compelling reasons. The risk of convulsions may increase in patients taking tramadol and concomitant medication that can lower the seizure threshold. (See Section 4.5 Interactions with other Medicaments and other forms of Interaction).
Tramadol should be used with caution in patients with head injury, increased intracranial pressure, severe impairment of hepatic and renal function and in patients prone to convulsive disorders or in shock.
Care should be taken when treating patients with respiratory depression, or if concomitant CNS depressant drugs are being administered, as the possibility of respiratory depression cannot be excluded in these situations. At therapeutic doses respiratory depression has infrequently been reported.
4.5 Interaction With Other Medicinal Products And Other Forms Of Interaction
Concurrent administration of tramadol with other centrally acting drugs, including alcohol, may potentiate CNS depressant effects.
Simultaneous treatment with carbamazepine may shorten the analgesic effect as a result of a reduction in serum levels of tramadol and its active metabolite.
Co-administration with cimetidine is associated with a small prolongation of the half-life of tramadol, but this is not clinically relevant.
Tramadol can induce convulsions and increase the potential for both selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs) anti-psychotics and other seizure threshold lowering drugs to cause convulsions (see Section 4.4 Special Warnings and Special Precautions for Use and 5.2 Pharmacokinetic Properties). Co-administration with SSRIs may lead to an increase in 5HT associated effects.
Co-administered ritonavir may increase serum concentrations of tramadol resulting in tramadol toxicity.
Digoxin toxicity has occurred rarely during co-administration of digoxin and tramadol.
MAO inhibitors: A serotoninergic syndrome is likely to occur: diarrhoea, tachycardia, sweating, tremor, confusion, coma. In case of recent treatment with MAOIs, treatment with tramadol should not be started until 15 days after cessation of treatment with MAOIs.
Other morphine derivatives (including anti-tussives, substitution treatments), benzodiazepines, barbiturates: Increased risk of respiratory depression, that may be fatal in overdosage.
Mixed agonists/antagonists (e.g. buprenorphine, nalbuphine and pentazocine): The analgesic effect of tramadol which is a pure agonist may be reduced, and a withdrawal syndrome may occur.
There have been isolated reports of interaction with coumarin anticoagulants resulting in an increased INR and so care should be taken when commencing treatment with tramadol in patients on anticoagulants.
4.6 Pregnancy And Lactation
There are no adequate data from the use of tramadol in pregnant women. Animal studies have shown reproductive toxicity, but not teratogenic effects (see section 5.3). Tramadol crosses the placental barrier and chronic use during pregnancy can cause withdrawal symptoms in the new-born baby. Therefore, it should not be used during pregnancy.
Tramadol administered before or during birth does not affect uterine contractility. In neonates it may induce changes in respiratory rate which are not usually clinically relevant.
During lactation very small amounts of tramadol and its metabolites (approximately 0.1% of an intravenous dose) are found in human breast milk. Therefore tramadol should not be administered during breast feeding.
4.7 Effects On Ability To Drive And Use Machines
Tramadol may cause drowsiness, blurred vision and dizziness which may be enhanced by alcohol or other CNS depressants. If affected, the patient should not drive or operate machinery.
4.8 Undesirable Effects
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4.9 Overdose
Symptoms of overdosage are typical of other opioid analgesics, and include miosis, vomiting, cardiovascular collapse, sedation and coma, seizures and respiratory depression.
Supportive measures such as maintaining the patency of the airway and maintaining cardiovascular function should be instituted; naloxone should be used to reverse respiratory depression; fits can be controlled with diazepam.
Tramadol is minimally eliminated from the serum by haemodialysis or haemofiltration. Therefore treatment of acute intoxication with tramadol with haemodialysis or haemofiltration alone is not suitable for detoxification.
Emptying the gastric contents is useful to remove any unabsorbed drug, particularly when a prolonged release formulation has been taken.
5. Pharmacological Properties
5.1 Pharmacodynamic Properties
Tramadol is a centrally acting analgesic (NO2A X 02). It is a non selective pure agonist at mu, delta and kappa opioid receptors with a higher affinity for the mu receptor. Other mechanisms that may contribute to its analgesic effect are inhibition of neuronal re-uptake of noradrenaline and 5HT .
5.2 Pharmacokinetic Properties
Following oral administration of a single dose, tramadol is almost completely absorbed and the absolute bioavailability is approximately 70%. Tramadol is metabolised to O-desmethyltramadol, which has been shown to have analgesic activity in rodents. The elimination half life of tramadol is around 6 hours, although this is extended to around 16 hours following prolonged absorption from the ZYDOL XL tablet.
Following administration of one ZYDOL XL tablet 200 mg in the fasting state, a mean peak plasma concentration (Cmax) of 192 ng.ml-1 was attained. This was associated with a median tmax of 6 hours (range 4-8 hours). The availability of tramadol from the ZYDOL XL tablet 200 mg was complete when compared with an immediate release tramadol solution 100 mg, after dose adjustment. In the presence of food, the availability and controlled release properties of ZYDOL XL tablets were maintained, with no evidence of dose-dumping.
A single dose-proportionality study has confirmed a linear pharmacokinetic response (in relation to tramadol and O-desmethyltramadol) following administration of the 200 mg, 300 mg and 400 mg tablets. A steady state study has confirmed the dose adjusted bioequivalence of the 150 mg and 200 mg tablets administered once-daily. This study also confirmed that the
ZYDOL XL tablet 150 mg provided an equivalent peak concentration and extent of availability of tramadol to an immediate release capsule 50 mg administered 8-hourly. On this basis it is recommended that patients receiving immediate release tramadol should be transferred initially to the nearest daily dose of ZYDOL XL tablets. It may be necessary to titrate the dose thereafter.
A further steady state study has demonstrated that immediate release tramadol tablets 50 mg, administered 6-hourly, provided plasma concentrations that were greater than would have been anticipated following administration of a single dose. This observation is consistent with a non-linear elimination of the drug substance. In contrast, the plasma concentrations from ZYDOL XL tablet 200 mg administered once-daily were in line with single dose data, confirming that the controlled delivery of tramadol from ZYDOL XL minimises the non-linearity associated with faster-releasing preparations. The more predictable plasma concentrations may lead to a more manageable dose titration process.
5.3 Preclinical Safety Data
Preclinical data reveal no special hazard for humans based on conventional studies of safety pharmacology, repeated dose toxicity, genotoxicity or carcinogenic potential.
Studies in rats and rabbits have revealed no teratogenic effects. However, embryotoxicity was shown in the form of delayed ossification. Fertility, reproductive performance and development of offspring were unaffected.
6. Pharmaceutical Particulars
6.1 List Of Excipients
Tablet core
Hydrogenated vegetable oil
Talc
Magnesium stearate
Film coat
Lactose monohydrate
Hypromellose (E464)
Titanium dioxide (E171)
Macrogol 4000
6.2 Incompatibilities
None known.
6.3 Shelf Life
Three years.
6.4 Special Precautions For Storage
Do not store above 30C.
6.5 Nature And Contents Of Container
1) PVC blisters with aluminium backing foil (containing 2, 7, 14, 28, 30, 56 or 60 tablets).
2) Polypropylene containers with polyethylene lids (containing 2, 7, 14, 28, 30, 56 or 60 tablets).
Not all pack sizes may be marketed.
6.6 Special Precautions For Disposal And Other Handling
None.
Administrative Data
7. Marketing Authorisation Holder
Napp Pharmaceuticals Ltd
Cambridge Science Park
Milton Road
Cambridge
CB4 0GW
8. Marketing Authorisation Number(S)
PL 16950/0091
9. Date Of First Authorisation/Renewal Of The Authorisation
14 June 1999
10. Date Of Revision Of The Text
14.12.2005
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