Nonsteroidal anti-inflammatory drugs (NSAIDs) have been the mainstay of treatment for the symptoms of arthritis. Doctors often advise patients to use over-the-counter preparations … or even prescription NSAID use for more serious problems.
Unfortunately, NSAIDs have many potential side effects including the potential for creating ulcers of the stomach and small intestine, kidney dysfunction, liver damage, fluid retention and increased incidence small but real cardiovascular events.
So … a real dilemma for many physicians is how to manage arthritis pain in patients for whom NSAIDs have already caused problems or for patients who have the potential to develop problems.
A drug that has been used primarily to control pain is tramadol (Ultram). This is a drug that is a mild narcotic centrally acting with little addictive potential.
Tramadol is increasingly used for treatment of osteoarthritis (OA) because it does not produce gastrointestinal bleeding or kidney problems, and does not adversely affect the cartilage, a controversial side effect, but potential associated with NSAIDs.
A recent study attempted to determine the analgesic efficacy, effect on physical function, duration of benefits and safety of oral tramadol in patients with OA.
(Cepeda MS, et al. J Rheumatol. 2007; 34:543-545)
The scientists searched the registry Cochrane Controlled Trials (CENTRAL), MEDLINE, Embase, and Lilacs databases up to August 2005.
We included randomized controlled trials (RCTs) evaluating the effect of tramadol or tramadol plus paracetamol (acetaminophen equivalent) on the levels of pain and / or physical function.
The researchers included 11 RCTs with a total of 1019 participants who received tramadol or tramadol / paracetamol and 920 participants who received placebo or active control. Participants who received tramadol informed (1) less pain, a relative decrease of 12% in pain intensity, (2) greater overall improvement, one out of 6 people taking paracetamol tramadol or tramadol / exhibited at least moderate global improvement, and (3) improving the stiffness and function than patients receiving placebo. In terms of adverse events, one of every 5 participants who received tramadol or tramadol / paracetamol experienced minor adverse events and one of every eight stopped taking the medication because of adverse events compared with participants who received placebo.
They concluded that tramadol and tramadol / decrease in pain intensity, produces relief symptoms and improving function in osteoarthritis patients, but these benefits were small.
In practice, Tramadol is a drug that is added often to a NSAID for better pain control or used in place of an NSAID in patients at high risk. As with most therapies, the response of a patient often depends on the expectations of the physician.
Caution should be exercised when using tramadol.
First, particularly in elderly patients dosage must start at a low level, probably 25 milligrams per day, with gradual increase to tolerance.
Secondly, there have been sporadic reports of increased risk of seizures in patients taking anti-depressants, including selective inhibitors of serotonin reuptake (SSRIs).
Tramadol also should be reduced when stopped.
There are some potential drug interactions, which should be evaluated.
An extended-release form of tramadol (Ultram ER) is now available in the U.S. and seems to have a good tolerance profile.
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