- Approval Id
- 096a082aaa55c602
- Drug Approval Emc Name
- Tramacet 37.5 mg/325 mg effervescent tablets
- Drug Name
- Tramacet 37.5 mg/325 mg effervescent tablets
- Company Name
- Grunenthal Ltd
- Company Address
- TOR Building, Saint Cloud Way, Maidenhead, Berkshire, SL6 8BN, UK
- Company Website
- http://www.grunenthal.co.uk
- Company Medical Info Direct Line
- +44 (0)800 254 5540
- Company Medical Info Email
- ukmedicalinformation@grunenthal.com
- Atc Code
- N02AJ13
- Legal Category
- Prescription only medicine
- Authorisation Holder
- Grünenthal Pharma Ltd
4045 Kingswood Road
Citywest Business Park
Citywest
Co. Dublin
Ireland
- Authorisation Number
- PL 50414/0025
- Authorisation Date
- 23/02/2014
- Instruction Authorisation Holder
- Grünenthal Pharma Ltd
4045 Kingswood Road
Citywest Business Park
Citywest
Co. Dublin
Ireland
- Instruction Authorisation Number
- PL 50414/0025
- Instruction Authorisation Date
- 23/02/2014
- Instruction Composition
- One effervescent tablet contains 37.5 mg tramadol hydrochloride and 325 mg paracetamol.
Excipients: Each effervescent tablet contains 7.8 mmol (or 179.3 mg) of sodium (as monosodium citrate, sodium hydrogen carbonate, and saccharin sodium).
One effervescent tablet contains 0.4 mg sunset yellow E110. One effervescent tablet contains up to 0.00085 mg sulphite per tablet.
For the full list of excipients, see section 6.1.
- Instruction Dosage Form
- Effervescent tablet
Off white to slightly rosy coloured with some coloured speckles, of round shape, flat with bevelled edges
- Instruction Clinical Particulars
- 4.1 Therapeutic indications
Tramacet is indicated for the symptomatic treatment of moderate to severe pain.
The use of Tramacet should be restricted to patients whose moderate to severe pain is considered to require a combination of tramadol hydrochloride and paracetamol (see also section 5.1).4.2 Posology and method of administration
\*Posology\*
The use of Tramacet should be restricted to patients whose moderate to severe pain is considered to require a combination of tramadol hydrochloride and paracetamol.
The dose should be adjusted to intensity of pain and the sensitivity of the individual patient. The lowest effective dose for analgesia should generally be selected. The total dose of 8 tablets (equivalent to 300 mg tramadol hydrochloride and 2600 mg paracetamol) per day should not be exceeded. The dosing interval should not be less than six hours.
\*\*Adults and adolescents (12 years and older)\*\*
An initial dose of two effervescent tablets of Tramacet (equivalent to 75 mg tramadol hydrochloride and 650 mg paracetamol) is recommended. Additional doses can be taken as needed, not exceeding 8 effervescent tablets (equivalent to 300 mg tramadol hydrochloride and 2600 mg paracetamol) per day.
The dosing interval should not be less than six hours.
Tramacet should under no circumstances be administered for longer than is strictly necessary (see also section 4.4). If repeated use or long term treatment with Tramacet is required as a result of the nature and severity of the illness, then careful, regular monitoring should take place (with breaks in the treatment, where possible), to assess whether continuation of the treatment is necessary.
\*\*Paediatric population\*\*
The effective and safe use of Tramacet has not been established in children below the age of 12 years. Treatment is therefore not recommended in this population.
\*\*Older people\*\*
A dose adjustment is not usually necessary in patients up to 75 years without clinically manifest hepatic or renal insufficiency. In elderly patients over 75 years elimination may be prolonged. Therefore, if necessary the dosage interval is to be extended according to the patient's requirements.
\*\*Renal insufficiency/dialysis\*\*
In patients with renal insufficiency the elimination of tramadol is delayed. In these patients prolongation of the dosage intervals should be carefully considered according to the patient's requirements.
\*\*Hepatic impairment\*\*
In patients with hepatic impairment the elimination of tramadol is delayed. In these patients prolongation of the dosage intervals should be carefully considered according to the patient's requirements (see section 4.4). Because of the presence of paracetamol Tramacet effervescent should not be used in patients with severe hepatic impairment (see section 4.3).
\*Method of administration\*
Oral use
Effervescent tablets should be taken dissolved in a glass of drinking water.
Treatment goals and discontinuation
Before initiating treatment with Tramacet, a treatment strategy including treatment duration and treatment goals, and a plan for end of the treatment, should be agreed together with the patient, in accordance with pain management guidelines. During treatment, there should be frequent contact between the physician and the patient to evaluate the need for continued treatment, consider discontinuation and to adjust dosages if needed. When a patient no longer requires therapy with tramadol, it may be advisable to taper the dose gradually to prevent symptoms of withdrawal. In absence of adequate pain control, the possibility of hyperalgesia, tolerance and progression of underlying disease should be considered (see section 4.4).4.3 Contraindications
- Hypersensitivity to the active substances, sunset yellow or to any of the excipients listed in section 6.1,
- acute intoxication with alcohol, hypnotic medicinal products, centrally-acting analgesics, opioids or psychotropic medicinal products,
- Tramacet should not be administered to patients who are receiving monoamine oxidase inhibitors or within two weeks of their withdrawal (see section 4.5),
- severe hepatic impairment,
- epilepsy not controlled by treatment (see section 4.4).4.4 Special warnings and precautions for use
\*Warnings:\*
- In adults and adolescents 12 years and older. The maximum dose of 8 tablets of Tramacet should not be exceeded. In order to avoid inadvertent overdose, patients should be advised not to exceed the recommended dose and not to use any other paracetamol (including over the counter) or tramadol hydrochloride containing products concurrently without the advice of a physician.
- In severe renal insufficiency (creatinine clearance <10 ml/mm), Tramacet is not recommended.
- In patients with severe hepatic impairment Tramacet should not be used (see section 4.3). The hazards of paracetamol overdose are greater in patients with non-cirrhotic alcoholic liver disease. In moderate cases prolongation of dosage interval should be carefully considered.
- In severe respiratory insufficiency, Tramacet is not recommended.
- Tramadol hydrochloride is not suitable as a substitute in opioid-dependent patients. Although it is an opioid agonist, tramadol hydrochloride cannot suppress morphine withdrawal symptoms.
- Convulsions have been reported in tramadol hydrochloride-treated patients susceptible to seizures or taking other medications that lower the seizure threshold, especially selective serotonin re-uptake inhibitors, tricyclic antidepressants, antipsychotics, centrally acting analgesics or local anaesthesia. Epileptic patients controlled by a treatment or patients susceptible to seizures should be treated with Tramacet only if there are compelling circumstances. Convulsions have been reported in patients receiving tramadol hydrochloride at the recommended dose levels. The risk may be increased when doses of tramadol hydrochloride exceed the recommended upper dose limit.
- Concomitant use of opioid agonists-antagonists (nalbuphine, buprenorphine, pentazocine) is not recommended (see section 4.5).
\*\*Sleep-related breathing disorders\*\*
Opioids can cause sleep-related breathing disorders including central sleep apnea (CSA) and sleep-related hypoxemia. Opioid use increases the risk of CSA in a dose-dependent fashion. In patients who present with CSA, consider decreasing the total opioid dosage.
Serotonin syndrome
Serotonin syndrome, a potentially life-threatening condition, has been reported in patients receiving tramadol in combination with other serotonergic agents or tramadol alone (see sections 4.5, 4.8 and 4.9).
If concomitant treatment with other serotonergic agents is clinically warranted, careful observation of the patient is advised, particularly during treatment initiation and dose escalations.
Symptoms of serotonin syndrome may include mental status changes, autonomic instability, neuromuscular abnormalities and/or gastrointestinal symptoms.
If serotonin syndrome is suspected, a dose reduction or discontinuation of therapy should be considered depending on the severity of the symptoms. Withdrawal of the serotonergic drugs usually brings about a rapid improvement.
\*\*CYP2D6 metabolism\*\*
Tramadol is metabolised by the liver enzyme CYP2D6. If a patient has a deficiency or is completely lacking this enzyme an adequate analgesic effect may not be obtained. Estimates indicate that up to 7% of the Caucasian population may have this deficiency. However, if the patient is an ultra-rapid metaboliser there is a risk of developing side effects of opioid toxicity even at commonly prescribed doses.
General symptoms of opioid toxicity include confusion, somnolence, shallow breathing, small pupils, nausea, vomiting, constipation and lack of appetite. In severe cases this may include symptoms of circulatory and respiratory depression, which may be life threatening and very rarely fatal. Estimates of prevalence of ultra-rapid metabolisers in different populations are summarised below:
| | |
| --- | --- |
| \*\*Population\*\* African/Ethiopian African American Asian Caucasian Greek Hungarian Northern European | \*\*Prevalence %\*\* 29% 3.4% to 6.5% 1.2% to 2% 3.6% to 6.5% 6.0% 1.9% 1% to 2% |
\*\*Post-operative use in children\*\*
There have been reports in the published literature that tramadol given post-operatively in children after tonsillectomy and/or adenoidectomy for obstructive sleep apnoea, led to rare, but life threatening adverse events. Extreme caution should be exercised when tramadol is administered to children for post-operative pain relief and should be accompanied by close monitoring for symptoms of opioid toxicity including respiratory depression.
\*\*Children with compromised respiratory function\*\*
Tramadol is not recommended for use in children in whom respiratory function might be compromised including neuromuscular disorders, severe cardiac or respiratory conditions, upper respiratory or lung infections, multiple trauma or extensive surgical procedures. These factors may worsen symptoms of opioid toxicity.
Adrenal insufficiency
Opioid analgesics may occasionally cause reversible adrenal insufficiency requiring monitoring and glucocorticoid replacement therapy. Symptoms of acute or chronic adrenal insufficiency may include e.g. severe abdominal pain, nausea and vomiting, low blood pressure, extreme fatigue, decreased appetite, and weight loss.
\*Precautions for use\*
\*Risk from concomitant use of sedative medicines such as benzodiazepines or related drugs\*
Concomitant use of Tramacet and sedative medicines such as benzodiazepines or related drugs may result in sedation, respiratory depression, coma and death. Because of these risks, concomitant prescribing with these sedative medicines should be reserved for patients for whom alternative treatment options are not possible. If a decision is made to prescribe Tramacet concomitantly with sedative medicines, the lowest effective dose should be used, and the duration of the concomitant treatment should be as short as possible.
Caution is advised if paracetamol is administered concomitantly with flucloxacillin due to increased risk of high anion gap metabolic acidosis (HAGMA), particularly in patients with severe renal impairment, sepsis, malnutrition and other sources of glutathione deficiency (e.g. chronic alcoholism) , as well as those using maximum daily doses of paracetamol. Close monitoring, including measurement of urinary 5-oxoproline, is recommended.
The patients should be followed closely for signs and symptoms of respiratory depression and sedation. In this respect, it is strongly recommended to inform patients and their caregivers to be aware of these symptoms (see section 4.5).
Tolerance and opioid use disorder (abuse and dependence)
Tolerance, physical and psychological dependence, and opioid use disorder (OUD) may develop upon repeated administration of opioids such as Tramacet. Repeated use of Tramacet can lead to opioid use disorder (OUD). A higher dose and longer duration of opioid treatment can increase the risk of developing OUD. Abuse or intentional misuse of Tramacet may result in overdose and/or death. The risk of developing OUD is increased in patients with a personal or a family history (parents or siblings) of substance use disorders (including alcohol use disorder), in current tobacco users or in patients with a personal history of other mental health disorders (e.g. major depression, anxiety and personality disorders).
Before initiating treatment with Tramacet and during the treatment, treatment goals and a discontinuation plan should be agreed with the patient (see section 4.2). Before and during treatment the patient should also be informed about the risks and signs of OUD. If these signs occur, patients should be advised to contact their physician.
Patients will require monitoring for signs of drug-seeking behaviour (e.g. too early requests for refills). This includes the review of concomitant opioids and psycho-active drugs (like benzodiazepines). For patients with signs and symptoms of OUD, consultation with an addiction specialist should be considered.
Tramacet should be used with caution in patients with cranial trauma, in patients prone to convulsive disorder, biliary tract disorders, in a state of shock, in an altered state of consciousness for unknown reasons, with problems affecting the respiratory center or the respiratory function, or with an increased intracranial pressure.
Paracetamol in overdose may cause hepatic toxicity in some patients.
Symptoms of withdrawal reaction, similar to those occurring during opiate withdrawal, may occur even at therapeutic doses and for short term treatment (see section 4.8). When a patient no longer requires therapy with Tramacet, it may be advisable to taper the dose gradually to prevent symptoms of withdrawal, especially after long treatment periods. Rarely, cases of dependence and abuse have been reported (see section 4.8).
In one study, use of tramadol hydrochloride during general anaesthesia with enflurane and nitrous oxide was reported to enhance intra-operative recall. Until further information is available, use of tramadol hydrochloride during light planes of anaesthesia should be avoided.
The colorant Sunset yellow E110 may cause allergic reactions.
The flavouring agent Orange flavour in this medicinal product contains low amounts of sulphite which may rarely cause severe hypersensitivity reactions and bronchospasm.
This medicinal product contains 179.3 mg of sodium per effervescent tablet, equivalent to 9.0% of the WHO recommended maximum daily intake for sodium.
The maximum daily dose of this product (8 effervescent tablets) is equivalent to 71.2% of the WHO recommended maximum daily dietary intake for sodium.
Tramacet is considered high in sodium. This should be particularly taken into account for those on a low salt diet.4.5 Interaction with other medicinal products and other forms of interaction
\*Concomitant use is contraindicated with:\*
• Non-selective MAO Inhibitors
Risk of serotonergic syndrome: diarrhoea, tachycardia, hyperhidrosis, trembling, confusional state, even coma.
• Selective-A MAO Inhibitors
Extrapolation from non-selective MAO inhibitors
Risk of serotonergic syndrome: diarrhoea, tachycardia, hyperhidrosis, trembling, confusional state, even coma.
• Selective-B MAO Inhibitors
Central excitation symptoms evocative of a serotonergic syndrome: diarrhoea, tachycardia, hyperhidrosis, trembling, confusional state, even coma.
In case of recent treatment with MAO inhibitors, a delay of two weeks should occur before treatment with tramadol hydrochloride
\*Concomitant use is not recommended with:\*
• Alcohol
Alcohol increases the sedative effect of opioid analgesics.
The effect on alertness can make driving of vehicles and the use of machines dangerous.
Avoid intake of alcoholic drinks and of medicinal products containing alcohol.
• Carbamazepine and other enzyme inducers
Risk of reduced efficacy and shorter duration due to decreased plasma concentrations of tramadol.
• Opioid agonists-antagonists (buprenorphine, nalbuphine, pentazocine)
Decrease of the analgesic effect by competitive blocking effect at the receptors, with the risk of occurrence of withdrawal syndrome.
\*Concomitant use which needs to be taken into consideration:\*
• Tramadol can induce convulsions and increase the potential for selective serotonin re-uptake inhibitors (SSRIs), serotonin-norepinephrine re-uptake inhibitors (SNRIs), tricyclic antidepressants, antipsychotics and seizure threshold-lowering medicinal products (such as bupropion, mirtazapine, tetrahydrocannabinol) to cause convulsions.
• Concomitant therapeutic use of tramadol hydrochloride and serotonergic drugs such as selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), MAO inhibitors (see section 4.3), tricyclic antidepressants and mirtazapine may cause serotonin syndrome, a potentially life-threatening condition (see sections 4.4 and 4.8).
• Other opioid derivatives (including antitussive medicinal products and substitutive treatments). Increased risk of respiratory depression which can be fatal in cases of overdose.
• Other central nervous system depressants, such as other opioid derivatives (including antitussive medicinal products and substitutive treatments), other anxiolytics, hypnotics, sedative antidepressants, sedative antihistamines, neuroleptics, centrally-acting antihypertensive medicinal products, thalidomide and baclofen.
These active substances can cause increased central depression. The effect on alertness can make driving of vehicles and the use of machines dangerous.
• Sedating medicinal products such as benzodiazepines or related substances:
The concomitant use of opioids with sedative medicines such as benzodiazepines or related drugs increases the risk of sedation, respiratory depression, coma and death because of additive CNS depressant effects. The dose and duration of the concomitant use should be limited (see section 4.4).
• The concomitant use of Tramacet with gabapentinoids (gabapentin and pregabalin) may result in respiratory depression, hypotension, profound sedation, coma or death.
• As medically appropriate, periodic evaluation of prothrombin time should be performed when Tramacet and warfarin like compounds are administered concurrently due to reports of increased INR.
• Caution should be taken when paracetamol is used concomitantly with flucloxacillin, as concurrent intake has been associated with high anion gap metabolic acidosis, especially in patients with risk factors (see section 4.4).
• In a limited number of studies the pre- or postoperative application of the antiemetic 5-HT3 antagonist ondansetron increased the requirement of tramadol hydrochloride in patients with postoperative pain.4.6 Fertility, pregnancy and lactation
\*Pregnancy\*
Since Tramacet is a fixed combination of active substances including tramadol hydrochloride, it should not be used during pregnancy.
Data regarding paracetamol:
Studies in animals are insufficient to conclude on reproductive toxicity. A large amount of data on pregnant women indicate neither malformative, nor feto/neonatal toxicity. Epidemiological studies on neurodevelopment in children exposed to paracetamol in utero show inconclusive results.
Data regarding tramadol:
There is inadequate evidence available to assess the safety of tramadol hydrochloride in pregnant women. Tramadol hydrochloride administered before or during birth does not affect uterine contractility. In neonates it may induce changes in the respiratory rate which are usually not clinically relevant. Long-term treatment during pregnancy may lead to withdrawal symptoms in the newborn after birth, as a consequence of habituation.
\*Breast-feeding:\*
Since Tramacet is a fixed combination of active ingredients including tramadol hydrochloride, it should not be used during lactation or alternatively, breast-feeding should be discontinued during treatment with Tramacet. Discontinuation of breast-feeding is generally not necessary following a single dose of Tramacet.
Data regarding paracetamol:
Paracetamol is excreted in breast milk but not in a clinically significant amount.
Data regarding tramadol:
Approximately 0.1% of the maternal dose of tramadol is excreted in breast milk. In the immediate post-partum period, for maternal oral daily dosage up to 400 mg, this corresponds to a mean amount of tramadol ingested by breast-fed infants of 3% of the maternal weight-adjusted dosage. For this reason tramadol should not be used during lactation or alternatively, breast-feeding should be discontinued during treatment with tramadol. Discontinuation of breast-feeding is generally not necessary following a single dose of tramadol.
\*Fertility\*
Post marketing surveillance does not suggest an effect of tramadol on fertility.
Animal studies did not show an effect of tramadol on fertility. No study on fertility was accomplished with the combination of tramadol and paracetamol4.7 Effects on ability to drive and use machines
Tramadol may cause drowsiness or dizziness, which may be enhanced by alcohol or other CNS depressants. If affected, the patient should not drive or operate machinery.
This medicine can impair cognitive function and can affect a patient's ability to drive safely. This class of medicine is in the list of drugs included in regulations under 5a of the Road Traffic Act 1988. When prescribing this medicine, patients should be told:
• The medicine is likely to affect your ability to drive
• Do not drive until you know how the medicine affects you
• It is an offence to drive while under the influence of this medicine
• However, you would not be committing an offence (called 'statutory defence') if:
| | | |
| --- | --- | --- |
| | o | The medicine has been prescribed to treat a medical or dental problem and |
| | o | You have taken it according to the instructions given by the prescriber and in the information provided with the medicine and |
| | o | It was not affecting your ability to drive safely |4.8 Undesirable effects
The most commonly reported undesirable effects during the clinical trials performed with the paracetamol/tramadol hydrochloride combination were nausea, dizziness and somnolence, observed in more than 10 % of the patients.
The frequencies are defined as follows:
| | |
| --- | --- |
| Very common: | ≥1/10 |
| Common: | ≥1/100 to <1/10 |
| Uncommon: | ≥1/1000 to <1/100 |
| Rare: | ≥1/10 000 to <1/1000 |
| Very rare: | <1/10 000 |
| Unknown: | Frequency cannot be estimated from the available data |
Within each frequency grouping, undesirable effects are presented in order of decreasing seriousness.
\*Cardiac disorders:\*
• Uncommon: arrhythmia, tachycardia, palpitations.
\*Eye disorders:\*
• Rare: vision blurred, miosis, mydriasis
\*Ear and labyrinth disorders:\*
• Uncommon: tinnitus
\*Gastrointestinal disorders:\*
• Very common: nausea
• Common: vomiting, constipation, dry mouth, diarrhoea, abdominal pain, dyspepsia, flatulence
• Uncommon: dysphagia, melaena.
\*General disorders and administration site conditions:\*
• Uncommon: chills, chest pain.
\*Investigations:\*
• Uncommon: transaminases increased.
\*Metabolism and nutrition disorders:\*
• Unknown: hypoglycaemia
\*Nervous system disorders:\*
• Very common: somnolence, dizziness
• Common: headache, trembling
• Uncommon: muscular contractions involuntary, paraesthesia, amnesia
• Rare: convulsions, ataxia, syncope, speech disorders.
\*Psychiatric disorders:\*
• Common: confusional state, mood altered, anxiety, nervousness, euphoric mood, sleep disorders
• Uncommon: depression, hallucinations, nightmares
• Rare: delirium, drug dependence
\*\*Post marketing surveillance\*\*
Very rare: abuse.
\*Renal and urinary disorders:\*
• Uncommon: albuminuria, micturition disorder (dysuria and urinary retention).
\*Respiratory, thoracic and mediastinal disorders:\*
• Uncommon: dyspnoea
\*Skin and subcutaneous tissue disorders:\*
• Common: hyperhidrosis, pruritus
• Uncommon: dermal reactions (e.g.rash, urticaria).
\*Vascular disorders:\*
• Uncommon: hypertension, hot flush
Drug dependence
Repeated use of Tramacet can lead to drug dependence, even at therapeutic doses. The risk of drug dependence may vary depending on a patient's individual risk factors, dosage, and duration of opioid treatment (see section 4.4).
Although not observed during clinical trials, the occurrence of the following undesirable effects known to be related to the administration of tramadol hydrochloride or paracetamol cannot be excluded:
\*\*\*\*Tramadol hydrochloride\*\*\*\*
• Postural hypotension, bradycardia, collapse.
• Post-marketing surveillance of tramadol hydrochloride has revealed rare alterations of warfarin effect, including elevation of prothrombin times.
• Rare cases (≥ 1/10000 to < 1/1000): allergic reactions with respiratory symptoms (e.g. dyspnoea, bronchospasm, wheezing, angioneurotic oedema) and anaphylaxis
• Rare cases (≥ 1/10000 to < 1/1000): changes in appetite, motor weakness, and respiratory depression
• Psychic side-effects may occur following administration of tramadol hydrochloride which vary individually in intensity and nature (depending on personality and duration of medication). These include changes in mood, (usually euphoric mood occasionally dysphoria), changes in activity (usually suppression occasionally increase) and changes in cognitive and sensorial capacity (e.g. decision behaviour perception disorders).
• Worsening of asthma has been reported though a causal relationship has not been established.
• Nervous system disorders: Not known: Serotonin syndrome.
• Symptoms of drug withdrawal syndrome, similar to those occurring during opiate withdrawal may occur as follows: agitation, anxiety, nervousness, insomnia, hyperkinesia, tremor and gastrointestinal symptoms. Other symptoms that have very rarely been seen if tramadol hydrochloride is discontinued abruptly include: panic attacks, severe anxiety, hallucinations, paraesthesia, tinnitus and unusual CNS symptoms.
• Respiratory, thoracic and mediastinal disorders: frequency not known: hiccups.
\*\*\*\*Paracetamol\*\*\*\*
• Adverse effects of paracetamol are rare but hypersensitivity including skin rash may occur. There have been reports of blood dyscrasias including thrombocytopenia and agranulocytosis, but these were not necessarily causally related to paracetamol.
• There have been several reports that suggest that paracetamol may produce hypoprothrombinemia when administered with warfarin-like compounds. In other studies, prothrombin time did not change.
• Very rare cases of serious skin reactions have been reported.
• Metabolism and nutrition disorders: cases of pyroglutamic acidosis (PGA) were reported with frequency not known, when paracetamol is used alone or with concomitant treatment of flucloxacillin, especially in patients with risk factors and prolonged treatment (see sections 4.4 and 4.5).
\*Reporting of suspected adverse reactions\*
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.4.9 Overdose
Tramacet is a fixed combination of active substances. In case of overdose, the symptoms may include the signs and symptoms of toxicity of tramadol hydrochloride or paracetamol or of both these active ingredients.
\*Symptoms of overdose from tramadol hydrochloride:\*
In principle, on intoxication with tramadol hydrochloride, symptoms similar to those of other centrally acting analgesics (opioids) are to be expected. These include in particular, miosis, vomiting, cardiovascular collapse, consciousness disorders up to coma, convulsions and respiratory depression up to respiratory arrest. Serotonin syndrome has also been reported.
\*Symptoms of overdose from paracetamol:\*
An overdose is of particular concern in young children. Symptoms of paracetamol overdosage in the first 24 hours are pallor, nausea, vomiting, anorexia and abdominal pain. Liver damage may become apparent 12 to 48 hours after ingestion. Abnormalities of glucose metabolism and metabolic acidosis may occur. In severe poisoning, hepatic failure may progress to encephalophathy, coma and death. Acute renal failure with acute tubular necrosis may develop even in the absence of severe liver damage. Cardiac arrhythmias and pancreatitis have been reported.
Liver damage is possible in adults who have taken 7.5-10 g or more of paracetamol. It is considered that excess quantities of a toxic metabolite (usually adequately detoxified by glutathione when normal doses of paracetamol are ingested), become irreversibly bound to liver tissue.
\*\*Emergency treatment:\*\*
- Transfer immediately to a specialised unit.
- Maintain respiratory and circulatory functions
- Prior to starting treatment, a blood sample should be taken as soon as possible after overdose in order to measure the plasma concentration of paracetamol and tramadol and in order to perform hepatic tests.
- Perform hepatic tests at the start (of overdose) and repeat every 24 hours. An increase in hepatic enzymes (ASAT, ALAT) is usually observed, which normalizes after one or two weeks.
- Empty the stomach by causing the patient to vomit (when the patient is conscious) by irritation or gastric lavage.
- 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 hydrochloride is minimally eliminated from the serum by haemodialysis or haemofiltration. Therefore treatment of acute intoxication with Tramacet with haemodialysis or haemofiltration alone is not suitable for detoxification.
Immediate treatment is essential in the management of paracetamol overdose. Despite a lack of significant early symptoms, patients should be referred to hospital urgently for immediate medical attention and any adult or adolescent who had ingested around 7.5 g or more of paracetamol in the preceding 4 hours or any child who has ingested ≥150 mg/kg of paracetamol in the preceding 4 hours should undergo gastric lavage. Paracetamol concentrations in blood should be measured later than 4 hours after overdose in order to be able to assess the risk of developing liver damage (via the paracetamol overdose nomogram). Administration of oral methionine or intravenous N-acetylcysteine (NAC) which may have a beneficial effect up to at least 48 hours after the overdose, may be required. Administration of intravenous NAC is most beneficial when initiated within 8 hours of overdose ingestion. However, NAC should still be given if the time to presentation is greater than 8 hours after overdose and continued for a full course of therapy. NAC treatment should be started immediately when massive overdose is suspected. General supportive measures must be available.
Irrespective of the reported quantity of paracetamol ingested, the antidote for paracetamol, NAC, should be administered orally or intravenously, as quickly as possible, if possible, within 8 hours following the overdose.
- Instruction Pharmacology
- 5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Opioids in combination with non-opioid analgesics; tramadol and paracetamol
ATC code: N02A J 13
\*\*ANALGESICS\*\*
Tramadol is an opioid analgesic that acts on the central nervous system. Tramadol is a pure non selective agonists of the μ, δ, and κ opioid receptors with a higher affinity for the µ receptors. Other mechanisms which contribute to its analgesic effect are inhibition of neuronal reuptake of noradrenaline and enhancement of serotonin release. Tramadol has an antitussive effect. Unlike morphine, a broad range of analgesic doses of tramadol has no respiratory depressant effect. Similarly, the gastro-intestinal motility is not modified. The cardiovascular effects are generally slight. The potency of tramadol is considered to be one-tenth to one-sixth that of morphine.
The precise mechanism of the analgesic properties of paracetamol is unknown and may involve central and peripheral effects.
Tramacet is positioned as a step II analgesic in the WHO pain ladder and should be utilised accordingly by the physician.5.2 Pharmacokinetic properties
Tramadol hydrochloride is administered in racemic form and the [-] and [+] forms of tramadol and its metabolite M1, are detected in the blood. Although tramadol is rapidly absorbed after administration, its absorption is slower (and its half-life longer) than that of paracetamol.
After a single oral administration of a tramadol hydrochloride/paracetamol (37.5 mg/325 mg) effervescent tablet, mean peak plasma concentrations of 94.1 ng/ml for racemic tramadol and 4.0 mcg/ml for paracetamol are reached after 1.1 h (racemic tramadol) and 0.5 h (paracetamol), respectively. The mean terminal phase half-lives (t1/2) are 5.7 h for racemic tramadol and 2.8 h for paracetamol.
During pharmacokinetic studies in healthy volunteers after single and repeated oral administration of Tramacet, no clinical significant change was observed in the kinetic parameters of each active ingredient compared to the parameters of the active ingredients used alone.
\*Absorption:\*
Racemic tramadol is rapidly and almost completely absorbed after oral administration. The mean absolute bioavailability of a single 100 mg dose is approximately 75%. After repeated administration, the bioavailability is increased and reaches approximately 90%.
After administration ofTramacet, the oral absorption of paracetamol is rapid and nearly complete and takes place mainly in the small intestine. Peak plasma concentrations of paracetamol are reached in one hour and are not modified by concomitant administration of tramadol hydrochloride.
The oral administration of Tramacet with food has no significant effect on the peak plasma concentration or extent of absorption of either tramadol or paracetamol so that Tramacet can be taken independently of meal times.
\*Distribution:\*
Tramadol has a high tissue affinity (Vd,β=203 ± 40 l). It has a plasma protein binding of about 20%.
Paracetamol appears to be widely distributed throughout most body tissues except fat. Its apparent volume of distribution is about 0.9 l/kg. A relative small portion (~20%) of paracetamol is bound to plasma proteins.
\*Metabolism:\*
Tramadol is extensively metabolized after oral administration. About 30% of the dose is excreted in urine as unchanged drug, whereas 60% of the dose is excreted as metabolites.
Tramadol is metabolised through O-demethylation (catalysed by the enzyme CYP2D6) to the metabolite M1, and through N-demethylation (catalysed by CYP3A) to the metabolite M2. M1 is further metabolised through N-demethylation and by conjugation with glucuronic acid. The plasma elimination half-life of M1 is 7 hours. The metabolite M1 has analgesic properties and is more potent than the parent drug. The plasma concentrations of M1 are several-fold lower than those of tramadol and the contribution to the clinical effect is unlikely to change on multiple dosing.
Paracetamol is principally metabolized in the liver through two major hepatic routes: glucuronidation and sulphation. The latter route can be rapidly saturated at doses above the therapeutic doses. A small fraction (less than 4%) is metabolized by cytochrome P 450 to an active intermediate (the N-acetyl benzoquinoneimine) which, under normal conditions of use, is rapidly detoxified by reduced glutathione and excreted in urine after conjugation to cysteine and mercapturic acid. However, during massive overdose, the quantity of this metabolite is increased.
\*Elimination:\*
Tramadol and its metabolites are eliminated mainly by the kidneys. The half-life of paracetamol is approximately 2 to 3 hours in adults. It is shorter in children and slightly longer in the newborn and in cirrhotic patients. Paracetamol is mainly eliminated by dose-dependent formation of glucuro- and sulpho-conjugate derivatives. Less than 9% of paracetamol is excreted unchanged in urine. In renal insufficiency, the half-life of both compounds is prolonged.5.3 Preclinical safety data
Conventional studies using the currently accepted standards for the evaluation of toxicity to reproduction and development are not available.
No preclinical study has been performed with the fixed combination (tramadol hydrochloride and paracetamol) to evaluate its carcinogenic or mutagenic effects or its effects on fertility.
No teratogenic effect that can be attributed to the medicine has been observed in the progeny of rats treated orally with the combination tramadol hydrochloride/paracetamol.
The combination tramadol hydrochloride/paracetamol has proven to be embryotoxic and foetotoxic in the rat at materno-toxic dose (50/434 mg/kg tramadol hydrochloride/paracetamol), i.e., 8.3 times the maximum therapeutic dose in man. No teratogenic effect has been observed at this dose. The toxicity to the embryo and the foetus results in a decreased foetal weight and an increase in supernumerary ribs. Lower doses, causing less severe materno-toxic effect (10/87 and 25/217 mg/kg tramadol hydrochloride/paracetamol) did not result in toxic effects in the embryo or the foetus.
Results of standard mutagenicity tests did not reveal a potential genotoxic risk for tramadol hydrochloride in man.
Results of carcinogenicity tests do not suggest a potential risk of tramadol hydrochloride for man.
Animal studies with tramadol hydrochloride revealed, at very high doses, effects on organ development, ossification and neonatal mortality, associated with maternotoxicity. Fertility reproductive performance and development of offspring were unaffected. Tramadol crosses the placenta. Male and female fertility was not affected.
Extensive investigations showed no evidence of a relevant genotoxic risk of paracetamol at therapeutic (i.e. non-toxic) doses.
Long-term studies in rats and mice yielded no evidence of relevant tumorigenic effects at non-hepatotoxic dosages of paracetamol.
Animal studies and extensive human experience to date yield no evidence of reproductive toxicity.
- Instruction Pharmaceutical Particulars
- 6.1 List of excipients
Monosodium citrate anhydrous
Citric acid anhydrous
Povidone K30
Sodium hydrogen carbonate
Macrogol 6000
Silica colloidal anhydrous
Magnesium stearate
Flavour Orange (maltodextrin (maize), modified starch (E1450), natural and artificial flavourings, sulphite)
Acesulfame potassium
Saccharin sodium
Sunset yellow E1106.2 Incompatibilities
Not applicable.6.3 Shelf life
Packed in coated aluminium strips:
24 months6.4 Special precautions for storage
Strip (Aluminium): Do not store above 25° C.6.5 Nature and contents of container
Child-resistant strips of thermo-sealed aluminium foil; outside coated with polyethylene terephthalate, inside coated with polyethylene.
Pack sizes of 2, 10, 20, 30, 40, 50, 60, 70, 80, 90 and 100 effervescent tablets packed in coated aluminium strips
Not all pack sizes may be marketed.6.6 Special precautions for disposal and other handling
Any unused product or waste material should be disposed of in accordance with local requirements.
- Instruction Content
- ## Composition
One effervescent tablet contains 37.5 mg tramadol hydrochloride and 325 mg paracetamol.
Excipients: Each effervescent tablet contains 7.8 mmol (or 179.3 mg) of sodium (as monosodium citrate, sodium hydrogen carbonate, and saccharin sodium).
One effervescent tablet contains 0.4 mg sunset yellow E110. One effervescent tablet contains up to 0.00085 mg sulphite per tablet.
For the full list of excipients, see section 6.1.
## Pharmaceutical Form
Effervescent tablet
Off white to slightly rosy coloured with some coloured speckles, of round shape, flat with bevelled edges
## Clinical Particulars
4.1 Therapeutic indications
Tramacet is indicated for the symptomatic treatment of moderate to severe pain.
The use of Tramacet should be restricted to patients whose moderate to severe pain is considered to require a combination of tramadol hydrochloride and paracetamol (see also section 5.1).4.2 Posology and method of administration
\*Posology\*
The use of Tramacet should be restricted to patients whose moderate to severe pain is considered to require a combination of tramadol hydrochloride and paracetamol.
The dose should be adjusted to intensity of pain and the sensitivity of the individual patient. The lowest effective dose for analgesia should generally be selected. The total dose of 8 tablets (equivalent to 300 mg tramadol hydrochloride and 2600 mg paracetamol) per day should not be exceeded. The dosing interval should not be less than six hours.
\*\*Adults and adolescents (12 years and older)\*\*
An initial dose of two effervescent tablets of Tramacet (equivalent to 75 mg tramadol hydrochloride and 650 mg paracetamol) is recommended. Additional doses can be taken as needed, not exceeding 8 effervescent tablets (equivalent to 300 mg tramadol hydrochloride and 2600 mg paracetamol) per day.
The dosing interval should not be less than six hours.
Tramacet should under no circumstances be administered for longer than is strictly necessary (see also section 4.4). If repeated use or long term treatment with Tramacet is required as a result of the nature and severity of the illness, then careful, regular monitoring should take place (with breaks in the treatment, where possible), to assess whether continuation of the treatment is necessary.
\*\*Paediatric population\*\*
The effective and safe use of Tramacet has not been established in children below the age of 12 years. Treatment is therefore not recommended in this population.
\*\*Older people\*\*
A dose adjustment is not usually necessary in patients up to 75 years without clinically manifest hepatic or renal insufficiency. In elderly patients over 75 years elimination may be prolonged. Therefore, if necessary the dosage interval is to be extended according to the patient's requirements.
\*\*Renal insufficiency/dialysis\*\*
In patients with renal insufficiency the elimination of tramadol is delayed. In these patients prolongation of the dosage intervals should be carefully considered according to the patient's requirements.
\*\*Hepatic impairment\*\*
In patients with hepatic impairment the elimination of tramadol is delayed. In these patients prolongation of the dosage intervals should be carefully considered according to the patient's requirements (see section 4.4). Because of the presence of paracetamol Tramacet effervescent should not be used in patients with severe hepatic impairment (see section 4.3).
\*Method of administration\*
Oral use
Effervescent tablets should be taken dissolved in a glass of drinking water.
Treatment goals and discontinuation
Before initiating treatment with Tramacet, a treatment strategy including treatment duration and treatment goals, and a plan for end of the treatment, should be agreed together with the patient, in accordance with pain management guidelines. During treatment, there should be frequent contact between the physician and the patient to evaluate the need for continued treatment, consider discontinuation and to adjust dosages if needed. When a patient no longer requires therapy with tramadol, it may be advisable to taper the dose gradually to prevent symptoms of withdrawal. In absence of adequate pain control, the possibility of hyperalgesia, tolerance and progression of underlying disease should be considered (see section 4.4).4.3 Contraindications
- Hypersensitivity to the active substances, sunset yellow or to any of the excipients listed in section 6.1,
- acute intoxication with alcohol, hypnotic medicinal products, centrally-acting analgesics, opioids or psychotropic medicinal products,
- Tramacet should not be administered to patients who are receiving monoamine oxidase inhibitors or within two weeks of their withdrawal (see section 4.5),
- severe hepatic impairment,
- epilepsy not controlled by treatment (see section 4.4).4.4 Special warnings and precautions for use
\*Warnings:\*
- In adults and adolescents 12 years and older. The maximum dose of 8 tablets of Tramacet should not be exceeded. In order to avoid inadvertent overdose, patients should be advised not to exceed the recommended dose and not to use any other paracetamol (including over the counter) or tramadol hydrochloride containing products concurrently without the advice of a physician.
- In severe renal insufficiency (creatinine clearance <10 ml/mm), Tramacet is not recommended.
- In patients with severe hepatic impairment Tramacet should not be used (see section 4.3). The hazards of paracetamol overdose are greater in patients with non-cirrhotic alcoholic liver disease. In moderate cases prolongation of dosage interval should be carefully considered.
- In severe respiratory insufficiency, Tramacet is not recommended.
- Tramadol hydrochloride is not suitable as a substitute in opioid-dependent patients. Although it is an opioid agonist, tramadol hydrochloride cannot suppress morphine withdrawal symptoms.
- Convulsions have been reported in tramadol hydrochloride-treated patients susceptible to seizures or taking other medications that lower the seizure threshold, especially selective serotonin re-uptake inhibitors, tricyclic antidepressants, antipsychotics, centrally acting analgesics or local anaesthesia. Epileptic patients controlled by a treatment or patients susceptible to seizures should be treated with Tramacet only if there are compelling circumstances. Convulsions have been reported in patients receiving tramadol hydrochloride at the recommended dose levels. The risk may be increased when doses of tramadol hydrochloride exceed the recommended upper dose limit.
- Concomitant use of opioid agonists-antagonists (nalbuphine, buprenorphine, pentazocine) is not recommended (see section 4.5).
\*\*Sleep-related breathing disorders\*\*
Opioids can cause sleep-related breathing disorders including central sleep apnea (CSA) and sleep-related hypoxemia. Opioid use increases the risk of CSA in a dose-dependent fashion. In patients who present with CSA, consider decreasing the total opioid dosage.
Serotonin syndrome
Serotonin syndrome, a potentially life-threatening condition, has been reported in patients receiving tramadol in combination with other serotonergic agents or tramadol alone (see sections 4.5, 4.8 and 4.9).
If concomitant treatment with other serotonergic agents is clinically warranted, careful observation of the patient is advised, particularly during treatment initiation and dose escalations.
Symptoms of serotonin syndrome may include mental status changes, autonomic instability, neuromuscular abnormalities and/or gastrointestinal symptoms.
If serotonin syndrome is suspected, a dose reduction or discontinuation of therapy should be considered depending on the severity of the symptoms. Withdrawal of the serotonergic drugs usually brings about a rapid improvement.
\*\*CYP2D6 metabolism\*\*
Tramadol is metabolised by the liver enzyme CYP2D6. If a patient has a deficiency or is completely lacking this enzyme an adequate analgesic effect may not be obtained. Estimates indicate that up to 7% of the Caucasian population may have this deficiency. However, if the patient is an ultra-rapid metaboliser there is a risk of developing side effects of opioid toxicity even at commonly prescribed doses.
General symptoms of opioid toxicity include confusion, somnolence, shallow breathing, small pupils, nausea, vomiting, constipation and lack of appetite. In severe cases this may include symptoms of circulatory and respiratory depression, which may be life threatening and very rarely fatal. Estimates of prevalence of ultra-rapid metabolisers in different populations are summarised below:
| | |
| --- | --- |
| \*\*Population\*\* African/Ethiopian African American Asian Caucasian Greek Hungarian Northern European | \*\*Prevalence %\*\* 29% 3.4% to 6.5% 1.2% to 2% 3.6% to 6.5% 6.0% 1.9% 1% to 2% |
\*\*Post-operative use in children\*\*
There have been reports in the published literature that tramadol given post-operatively in children after tonsillectomy and/or adenoidectomy for obstructive sleep apnoea, led to rare, but life threatening adverse events. Extreme caution should be exercised when tramadol is administered to children for post-operative pain relief and should be accompanied by close monitoring for symptoms of opioid toxicity including respiratory depression.
\*\*Children with compromised respiratory function\*\*
Tramadol is not recommended for use in children in whom respiratory function might be compromised including neuromuscular disorders, severe cardiac or respiratory conditions, upper respiratory or lung infections, multiple trauma or extensive surgical procedures. These factors may worsen symptoms of opioid toxicity.
Adrenal insufficiency
Opioid analgesics may occasionally cause reversible adrenal insufficiency requiring monitoring and glucocorticoid replacement therapy. Symptoms of acute or chronic adrenal insufficiency may include e.g. severe abdominal pain, nausea and vomiting, low blood pressure, extreme fatigue, decreased appetite, and weight loss.
\*Precautions for use\*
\*Risk from concomitant use of sedative medicines such as benzodiazepines or related drugs\*
Concomitant use of Tramacet and sedative medicines such as benzodiazepines or related drugs may result in sedation, respiratory depression, coma and death. Because of these risks, concomitant prescribing with these sedative medicines should be reserved for patients for whom alternative treatment options are not possible. If a decision is made to prescribe Tramacet concomitantly with sedative medicines, the lowest effective dose should be used, and the duration of the concomitant treatment should be as short as possible.
Caution is advised if paracetamol is administered concomitantly with flucloxacillin due to increased risk of high anion gap metabolic acidosis (HAGMA), particularly in patients with severe renal impairment, sepsis, malnutrition and other sources of glutathione deficiency (e.g. chronic alcoholism) , as well as those using maximum daily doses of paracetamol. Close monitoring, including measurement of urinary 5-oxoproline, is recommended.
The patients should be followed closely for signs and symptoms of respiratory depression and sedation. In this respect, it is strongly recommended to inform patients and their caregivers to be aware of these symptoms (see section 4.5).
Tolerance and opioid use disorder (abuse and dependence)
Tolerance, physical and psychological dependence, and opioid use disorder (OUD) may develop upon repeated administration of opioids such as Tramacet. Repeated use of Tramacet can lead to opioid use disorder (OUD). A higher dose and longer duration of opioid treatment can increase the risk of developing OUD. Abuse or intentional misuse of Tramacet may result in overdose and/or death. The risk of developing OUD is increased in patients with a personal or a family history (parents or siblings) of substance use disorders (including alcohol use disorder), in current tobacco users or in patients with a personal history of other mental health disorders (e.g. major depression, anxiety and personality disorders).
Before initiating treatment with Tramacet and during the treatment, treatment goals and a discontinuation plan should be agreed with the patient (see section 4.2). Before and during treatment the patient should also be informed about the risks and signs of OUD. If these signs occur, patients should be advised to contact their physician.
Patients will require monitoring for signs of drug-seeking behaviour (e.g. too early requests for refills). This includes the review of concomitant opioids and psycho-active drugs (like benzodiazepines). For patients with signs and symptoms of OUD, consultation with an addiction specialist should be considered.
Tramacet should be used with caution in patients with cranial trauma, in patients prone to convulsive disorder, biliary tract disorders, in a state of shock, in an altered state of consciousness for unknown reasons, with problems affecting the respiratory center or the respiratory function, or with an increased intracranial pressure.
Paracetamol in overdose may cause hepatic toxicity in some patients.
Symptoms of withdrawal reaction, similar to those occurring during opiate withdrawal, may occur even at therapeutic doses and for short term treatment (see section 4.8). When a patient no longer requires therapy with Tramacet, it may be advisable to taper the dose gradually to prevent symptoms of withdrawal, especially after long treatment periods. Rarely, cases of dependence and abuse have been reported (see section 4.8).
In one study, use of tramadol hydrochloride during general anaesthesia with enflurane and nitrous oxide was reported to enhance intra-operative recall. Until further information is available, use of tramadol hydrochloride during light planes of anaesthesia should be avoided.
The colorant Sunset yellow E110 may cause allergic reactions.
The flavouring agent Orange flavour in this medicinal product contains low amounts of sulphite which may rarely cause severe hypersensitivity reactions and bronchospasm.
This medicinal product contains 179.3 mg of sodium per effervescent tablet, equivalent to 9.0% of the WHO recommended maximum daily intake for sodium.
The maximum daily dose of this product (8 effervescent tablets) is equivalent to 71.2% of the WHO recommended maximum daily dietary intake for sodium.
Tramacet is considered high in sodium. This should be particularly taken into account for those on a low salt diet.4.5 Interaction with other medicinal products and other forms of interaction
\*Concomitant use is contraindicated with:\*
• Non-selective MAO Inhibitors
Risk of serotonergic syndrome: diarrhoea, tachycardia, hyperhidrosis, trembling, confusional state, even coma.
• Selective-A MAO Inhibitors
Extrapolation from non-selective MAO inhibitors
Risk of serotonergic syndrome: diarrhoea, tachycardia, hyperhidrosis, trembling, confusional state, even coma.
• Selective-B MAO Inhibitors
Central excitation symptoms evocative of a serotonergic syndrome: diarrhoea, tachycardia, hyperhidrosis, trembling, confusional state, even coma.
In case of recent treatment with MAO inhibitors, a delay of two weeks should occur before treatment with tramadol hydrochloride
\*Concomitant use is not recommended with:\*
• Alcohol
Alcohol increases the sedative effect of opioid analgesics.
The effect on alertness can make driving of vehicles and the use of machines dangerous.
Avoid intake of alcoholic drinks and of medicinal products containing alcohol.
• Carbamazepine and other enzyme inducers
Risk of reduced efficacy and shorter duration due to decreased plasma concentrations of tramadol.
• Opioid agonists-antagonists (buprenorphine, nalbuphine, pentazocine)
Decrease of the analgesic effect by competitive blocking effect at the receptors, with the risk of occurrence of withdrawal syndrome.
\*Concomitant use which needs to be taken into consideration:\*
• Tramadol can induce convulsions and increase the potential for selective serotonin re-uptake inhibitors (SSRIs), serotonin-norepinephrine re-uptake inhibitors (SNRIs), tricyclic antidepressants, antipsychotics and seizure threshold-lowering medicinal products (such as bupropion, mirtazapine, tetrahydrocannabinol) to cause convulsions.
• Concomitant therapeutic use of tramadol hydrochloride and serotonergic drugs such as selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), MAO inhibitors (see section 4.3), tricyclic antidepressants and mirtazapine may cause serotonin syndrome, a potentially life-threatening condition (see sections 4.4 and 4.8).
• Other opioid derivatives (including antitussive medicinal products and substitutive treatments). Increased risk of respiratory depression which can be fatal in cases of overdose.
• Other central nervous system depressants, such as other opioid derivatives (including antitussive medicinal products and substitutive treatments), other anxiolytics, hypnotics, sedative antidepressants, sedative antihistamines, neuroleptics, centrally-acting antihypertensive medicinal products, thalidomide and baclofen.
These active substances can cause increased central depression. The effect on alertness can make driving of vehicles and the use of machines dangerous.
• Sedating medicinal products such as benzodiazepines or related substances:
The concomitant use of opioids with sedative medicines such as benzodiazepines or related drugs increases the risk of sedation, respiratory depression, coma and death because of additive CNS depressant effects. The dose and duration of the concomitant use should be limited (see section 4.4).
• The concomitant use of Tramacet with gabapentinoids (gabapentin and pregabalin) may result in respiratory depression, hypotension, profound sedation, coma or death.
• As medically appropriate, periodic evaluation of prothrombin time should be performed when Tramacet and warfarin like compounds are administered concurrently due to reports of increased INR.
• Caution should be taken when paracetamol is used concomitantly with flucloxacillin, as concurrent intake has been associated with high anion gap metabolic acidosis, especially in patients with risk factors (see section 4.4).
• In a limited number of studies the pre- or postoperative application of the antiemetic 5-HT3 antagonist ondansetron increased the requirement of tramadol hydrochloride in patients with postoperative pain.4.6 Fertility, pregnancy and lactation
\*Pregnancy\*
Since Tramacet is a fixed combination of active substances including tramadol hydrochloride, it should not be used during pregnancy.
Data regarding paracetamol:
Studies in animals are insufficient to conclude on reproductive toxicity. A large amount of data on pregnant women indicate neither malformative, nor feto/neonatal toxicity. Epidemiological studies on neurodevelopment in children exposed to paracetamol in utero show inconclusive results.
Data regarding tramadol:
There is inadequate evidence available to assess the safety of tramadol hydrochloride in pregnant women. Tramadol hydrochloride administered before or during birth does not affect uterine contractility. In neonates it may induce changes in the respiratory rate which are usually not clinically relevant. Long-term treatment during pregnancy may lead to withdrawal symptoms in the newborn after birth, as a consequence of habituation.
\*Breast-feeding:\*
Since Tramacet is a fixed combination of active ingredients including tramadol hydrochloride, it should not be used during lactation or alternatively, breast-feeding should be discontinued during treatment with Tramacet. Discontinuation of breast-feeding is generally not necessary following a single dose of Tramacet.
Data regarding paracetamol:
Paracetamol is excreted in breast milk but not in a clinically significant amount.
Data regarding tramadol:
Approximately 0.1% of the maternal dose of tramadol is excreted in breast milk. In the immediate post-partum period, for maternal oral daily dosage up to 400 mg, this corresponds to a mean amount of tramadol ingested by breast-fed infants of 3% of the maternal weight-adjusted dosage. For this reason tramadol should not be used during lactation or alternatively, breast-feeding should be discontinued during treatment with tramadol. Discontinuation of breast-feeding is generally not necessary following a single dose of tramadol.
\*Fertility\*
Post marketing surveillance does not suggest an effect of tramadol on fertility.
Animal studies did not show an effect of tramadol on fertility. No study on fertility was accomplished with the combination of tramadol and paracetamol4.7 Effects on ability to drive and use machines
Tramadol may cause drowsiness or dizziness, which may be enhanced by alcohol or other CNS depressants. If affected, the patient should not drive or operate machinery.
This medicine can impair cognitive function and can affect a patient's ability to drive safely. This class of medicine is in the list of drugs included in regulations under 5a of the Road Traffic Act 1988. When prescribing this medicine, patients should be told:
• The medicine is likely to affect your ability to drive
• Do not drive until you know how the medicine affects you
• It is an offence to drive while under the influence of this medicine
• However, you would not be committing an offence (called 'statutory defence') if:
| | | |
| --- | --- | --- |
| | o | The medicine has been prescribed to treat a medical or dental problem and |
| | o | You have taken it according to the instructions given by the prescriber and in the information provided with the medicine and |
| | o | It was not affecting your ability to drive safely |4.8 Undesirable effects
The most commonly reported undesirable effects during the clinical trials performed with the paracetamol/tramadol hydrochloride combination were nausea, dizziness and somnolence, observed in more than 10 % of the patients.
The frequencies are defined as follows:
| | |
| --- | --- |
| Very common: | ≥1/10 |
| Common: | ≥1/100 to <1/10 |
| Uncommon: | ≥1/1000 to <1/100 |
| Rare: | ≥1/10 000 to <1/1000 |
| Very rare: | <1/10 000 |
| Unknown: | Frequency cannot be estimated from the available data |
Within each frequency grouping, undesirable effects are presented in order of decreasing seriousness.
\*Cardiac disorders:\*
• Uncommon: arrhythmia, tachycardia, palpitations.
\*Eye disorders:\*
• Rare: vision blurred, miosis, mydriasis
\*Ear and labyrinth disorders:\*
• Uncommon: tinnitus
\*Gastrointestinal disorders:\*
• Very common: nausea
• Common: vomiting, constipation, dry mouth, diarrhoea, abdominal pain, dyspepsia, flatulence
• Uncommon: dysphagia, melaena.
\*General disorders and administration site conditions:\*
• Uncommon: chills, chest pain.
\*Investigations:\*
• Uncommon: transaminases increased.
\*Metabolism and nutrition disorders:\*
• Unknown: hypoglycaemia
\*Nervous system disorders:\*
• Very common: somnolence, dizziness
• Common: headache, trembling
• Uncommon: muscular contractions involuntary, paraesthesia, amnesia
• Rare: convulsions, ataxia, syncope, speech disorders.
\*Psychiatric disorders:\*
• Common: confusional state, mood altered, anxiety, nervousness, euphoric mood, sleep disorders
• Uncommon: depression, hallucinations, nightmares
• Rare: delirium, drug dependence
\*\*Post marketing surveillance\*\*
Very rare: abuse.
\*Renal and urinary disorders:\*
• Uncommon: albuminuria, micturition disorder (dysuria and urinary retention).
\*Respiratory, thoracic and mediastinal disorders:\*
• Uncommon: dyspnoea
\*Skin and subcutaneous tissue disorders:\*
• Common: hyperhidrosis, pruritus
• Uncommon: dermal reactions (e.g.rash, urticaria).
\*Vascular disorders:\*
• Uncommon: hypertension, hot flush
Drug dependence
Repeated use of Tramacet can lead to drug dependence, even at therapeutic doses. The risk of drug dependence may vary depending on a patient's individual risk factors, dosage, and duration of opioid treatment (see section 4.4).
Although not observed during clinical trials, the occurrence of the following undesirable effects known to be related to the administration of tramadol hydrochloride or paracetamol cannot be excluded:
\*\*\*\*Tramadol hydrochloride\*\*\*\*
• Postural hypotension, bradycardia, collapse.
• Post-marketing surveillance of tramadol hydrochloride has revealed rare alterations of warfarin effect, including elevation of prothrombin times.
• Rare cases (≥ 1/10000 to < 1/1000): allergic reactions with respiratory symptoms (e.g. dyspnoea, bronchospasm, wheezing, angioneurotic oedema) and anaphylaxis
• Rare cases (≥ 1/10000 to < 1/1000): changes in appetite, motor weakness, and respiratory depression
• Psychic side-effects may occur following administration of tramadol hydrochloride which vary individually in intensity and nature (depending on personality and duration of medication). These include changes in mood, (usually euphoric mood occasionally dysphoria), changes in activity (usually suppression occasionally increase) and changes in cognitive and sensorial capacity (e.g. decision behaviour perception disorders).
• Worsening of asthma has been reported though a causal relationship has not been established.
• Nervous system disorders: Not known: Serotonin syndrome.
• Symptoms of drug withdrawal syndrome, similar to those occurring during opiate withdrawal may occur as follows: agitation, anxiety, nervousness, insomnia, hyperkinesia, tremor and gastrointestinal symptoms. Other symptoms that have very rarely been seen if tramadol hydrochloride is discontinued abruptly include: panic attacks, severe anxiety, hallucinations, paraesthesia, tinnitus and unusual CNS symptoms.
• Respiratory, thoracic and mediastinal disorders: frequency not known: hiccups.
\*\*\*\*Paracetamol\*\*\*\*
• Adverse effects of paracetamol are rare but hypersensitivity including skin rash may occur. There have been reports of blood dyscrasias including thrombocytopenia and agranulocytosis, but these were not necessarily causally related to paracetamol.
• There have been several reports that suggest that paracetamol may produce hypoprothrombinemia when administered with warfarin-like compounds. In other studies, prothrombin time did not change.
• Very rare cases of serious skin reactions have been reported.
• Metabolism and nutrition disorders: cases of pyroglutamic acidosis (PGA) were reported with frequency not known, when paracetamol is used alone or with concomitant treatment of flucloxacillin, especially in patients with risk factors and prolonged treatment (see sections 4.4 and 4.5).
\*Reporting of suspected adverse reactions\*
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.4.9 Overdose
Tramacet is a fixed combination of active substances. In case of overdose, the symptoms may include the signs and symptoms of toxicity of tramadol hydrochloride or paracetamol or of both these active ingredients.
\*Symptoms of overdose from tramadol hydrochloride:\*
In principle, on intoxication with tramadol hydrochloride, symptoms similar to those of other centrally acting analgesics (opioids) are to be expected. These include in particular, miosis, vomiting, cardiovascular collapse, consciousness disorders up to coma, convulsions and respiratory depression up to respiratory arrest. Serotonin syndrome has also been reported.
\*Symptoms of overdose from paracetamol:\*
An overdose is of particular concern in young children. Symptoms of paracetamol overdosage in the first 24 hours are pallor, nausea, vomiting, anorexia and abdominal pain. Liver damage may become apparent 12 to 48 hours after ingestion. Abnormalities of glucose metabolism and metabolic acidosis may occur. In severe poisoning, hepatic failure may progress to encephalophathy, coma and death. Acute renal failure with acute tubular necrosis may develop even in the absence of severe liver damage. Cardiac arrhythmias and pancreatitis have been reported.
Liver damage is possible in adults who have taken 7.5-10 g or more of paracetamol. It is considered that excess quantities of a toxic metabolite (usually adequately detoxified by glutathione when normal doses of paracetamol are ingested), become irreversibly bound to liver tissue.
\*\*Emergency treatment:\*\*
- Transfer immediately to a specialised unit.
- Maintain respiratory and circulatory functions
- Prior to starting treatment, a blood sample should be taken as soon as possible after overdose in order to measure the plasma concentration of paracetamol and tramadol and in order to perform hepatic tests.
- Perform hepatic tests at the start (of overdose) and repeat every 24 hours. An increase in hepatic enzymes (ASAT, ALAT) is usually observed, which normalizes after one or two weeks.
- Empty the stomach by causing the patient to vomit (when the patient is conscious) by irritation or gastric lavage.
- 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 hydrochloride is minimally eliminated from the serum by haemodialysis or haemofiltration. Therefore treatment of acute intoxication with Tramacet with haemodialysis or haemofiltration alone is not suitable for detoxification.
Immediate treatment is essential in the management of paracetamol overdose. Despite a lack of significant early symptoms, patients should be referred to hospital urgently for immediate medical attention and any adult or adolescent who had ingested around 7.5 g or more of paracetamol in the preceding 4 hours or any child who has ingested ≥150 mg/kg of paracetamol in the preceding 4 hours should undergo gastric lavage. Paracetamol concentrations in blood should be measured later than 4 hours after overdose in order to be able to assess the risk of developing liver damage (via the paracetamol overdose nomogram). Administration of oral methionine or intravenous N-acetylcysteine (NAC) which may have a beneficial effect up to at least 48 hours after the overdose, may be required. Administration of intravenous NAC is most beneficial when initiated within 8 hours of overdose ingestion. However, NAC should still be given if the time to presentation is greater than 8 hours after overdose and continued for a full course of therapy. NAC treatment should be started immediately when massive overdose is suspected. General supportive measures must be available.
Irrespective of the reported quantity of paracetamol ingested, the antidote for paracetamol, NAC, should be administered orally or intravenously, as quickly as possible, if possible, within 8 hours following the overdose.
## Pharmacological Properties
5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Opioids in combination with non-opioid analgesics; tramadol and paracetamol
ATC code: N02A J 13
\*\*ANALGESICS\*\*
Tramadol is an opioid analgesic that acts on the central nervous system. Tramadol is a pure non selective agonists of the μ, δ, and κ opioid receptors with a higher affinity for the µ receptors. Other mechanisms which contribute to its analgesic effect are inhibition of neuronal reuptake of noradrenaline and enhancement of serotonin release. Tramadol has an antitussive effect. Unlike morphine, a broad range of analgesic doses of tramadol has no respiratory depressant effect. Similarly, the gastro-intestinal motility is not modified. The cardiovascular effects are generally slight. The potency of tramadol is considered to be one-tenth to one-sixth that of morphine.
The precise mechanism of the analgesic properties of paracetamol is unknown and may involve central and peripheral effects.
Tramacet is positioned as a step II analgesic in the WHO pain ladder and should be utilised accordingly by the physician.5.2 Pharmacokinetic properties
Tramadol hydrochloride is administered in racemic form and the [-] and [+] forms of tramadol and its metabolite M1, are detected in the blood. Although tramadol is rapidly absorbed after administration, its absorption is slower (and its half-life longer) than that of paracetamol.
After a single oral administration of a tramadol hydrochloride/paracetamol (37.5 mg/325 mg) effervescent tablet, mean peak plasma concentrations of 94.1 ng/ml for racemic tramadol and 4.0 mcg/ml for paracetamol are reached after 1.1 h (racemic tramadol) and 0.5 h (paracetamol), respectively. The mean terminal phase half-lives (t1/2) are 5.7 h for racemic tramadol and 2.8 h for paracetamol.
During pharmacokinetic studies in healthy volunteers after single and repeated oral administration of Tramacet, no clinical significant change was observed in the kinetic parameters of each active ingredient compared to the parameters of the active ingredients used alone.
\*Absorption:\*
Racemic tramadol is rapidly and almost completely absorbed after oral administration. The mean absolute bioavailability of a single 100 mg dose is approximately 75%. After repeated administration, the bioavailability is increased and reaches approximately 90%.
After administration ofTramacet, the oral absorption of paracetamol is rapid and nearly complete and takes place mainly in the small intestine. Peak plasma concentrations of paracetamol are reached in one hour and are not modified by concomitant administration of tramadol hydrochloride.
The oral administration of Tramacet with food has no significant effect on the peak plasma concentration or extent of absorption of either tramadol or paracetamol so that Tramacet can be taken independently of meal times.
\*Distribution:\*
Tramadol has a high tissue affinity (Vd,β=203 ± 40 l). It has a plasma protein binding of about 20%.
Paracetamol appears to be widely distributed throughout most body tissues except fat. Its apparent volume of distribution is about 0.9 l/kg. A relative small portion (~20%) of paracetamol is bound to plasma proteins.
\*Metabolism:\*
Tramadol is extensively metabolized after oral administration. About 30% of the dose is excreted in urine as unchanged drug, whereas 60% of the dose is excreted as metabolites.
Tramadol is metabolised through O-demethylation (catalysed by the enzyme CYP2D6) to the metabolite M1, and through N-demethylation (catalysed by CYP3A) to the metabolite M2. M1 is further metabolised through N-demethylation and by conjugation with glucuronic acid. The plasma elimination half-life of M1 is 7 hours. The metabolite M1 has analgesic properties and is more potent than the parent drug. The plasma concentrations of M1 are several-fold lower than those of tramadol and the contribution to the clinical effect is unlikely to change on multiple dosing.
Paracetamol is principally metabolized in the liver through two major hepatic routes: glucuronidation and sulphation. The latter route can be rapidly saturated at doses above the therapeutic doses. A small fraction (less than 4%) is metabolized by cytochrome P 450 to an active intermediate (the N-acetyl benzoquinoneimine) which, under normal conditions of use, is rapidly detoxified by reduced glutathione and excreted in urine after conjugation to cysteine and mercapturic acid. However, during massive overdose, the quantity of this metabolite is increased.
\*Elimination:\*
Tramadol and its metabolites are eliminated mainly by the kidneys. The half-life of paracetamol is approximately 2 to 3 hours in adults. It is shorter in children and slightly longer in the newborn and in cirrhotic patients. Paracetamol is mainly eliminated by dose-dependent formation of glucuro- and sulpho-conjugate derivatives. Less than 9% of paracetamol is excreted unchanged in urine. In renal insufficiency, the half-life of both compounds is prolonged.5.3 Preclinical safety data
Conventional studies using the currently accepted standards for the evaluation of toxicity to reproduction and development are not available.
No preclinical study has been performed with the fixed combination (tramadol hydrochloride and paracetamol) to evaluate its carcinogenic or mutagenic effects or its effects on fertility.
No teratogenic effect that can be attributed to the medicine has been observed in the progeny of rats treated orally with the combination tramadol hydrochloride/paracetamol.
The combination tramadol hydrochloride/paracetamol has proven to be embryotoxic and foetotoxic in the rat at materno-toxic dose (50/434 mg/kg tramadol hydrochloride/paracetamol), i.e., 8.3 times the maximum therapeutic dose in man. No teratogenic effect has been observed at this dose. The toxicity to the embryo and the foetus results in a decreased foetal weight and an increase in supernumerary ribs. Lower doses, causing less severe materno-toxic effect (10/87 and 25/217 mg/kg tramadol hydrochloride/paracetamol) did not result in toxic effects in the embryo or the foetus.
Results of standard mutagenicity tests did not reveal a potential genotoxic risk for tramadol hydrochloride in man.
Results of carcinogenicity tests do not suggest a potential risk of tramadol hydrochloride for man.
Animal studies with tramadol hydrochloride revealed, at very high doses, effects on organ development, ossification and neonatal mortality, associated with maternotoxicity. Fertility reproductive performance and development of offspring were unaffected. Tramadol crosses the placenta. Male and female fertility was not affected.
Extensive investigations showed no evidence of a relevant genotoxic risk of paracetamol at therapeutic (i.e. non-toxic) doses.
Long-term studies in rats and mice yielded no evidence of relevant tumorigenic effects at non-hepatotoxic dosages of paracetamol.
Animal studies and extensive human experience to date yield no evidence of reproductive toxicity.
## Pharmaceutical Particulars
6.1 List of excipients
Monosodium citrate anhydrous
Citric acid anhydrous
Povidone K30
Sodium hydrogen carbonate
Macrogol 6000
Silica colloidal anhydrous
Magnesium stearate
Flavour Orange (maltodextrin (maize), modified starch (E1450), natural and artificial flavourings, sulphite)
Acesulfame potassium
Saccharin sodium
Sunset yellow E1106.2 Incompatibilities
Not applicable.6.3 Shelf life
Packed in coated aluminium strips:
24 months6.4 Special precautions for storage
Strip (Aluminium): Do not store above 25° C.6.5 Nature and contents of container
Child-resistant strips of thermo-sealed aluminium foil; outside coated with polyethylene terephthalate, inside coated with polyethylene.
Pack sizes of 2, 10, 20, 30, 40, 50, 60, 70, 80, 90 and 100 effervescent tablets packed in coated aluminium strips
Not all pack sizes may be marketed.6.6 Special precautions for disposal and other handling
Any unused product or waste material should be disposed of in accordance with local requirements.
