Mosby's 2014 Nursing Drug Reference (404 page)

Read Mosby's 2014 Nursing Drug Reference Online

Authors: Linda Skidmore-Roth

Canada only Side effects:
italics
= common;
bold
= life-threatening
Nurse Alert

traMADol (Rx)

(tram′a-dole)

Conzip, Rybix, Ryzolt, Ultram, Ultram ER, Zytram

Func. class.:
Analgesic—miscellaneous

Do not confuse:
traMADol
/Toradol

ACTION:

Binds to μ-opioid receptors, inhibits reuptake of norepinephrine, serotonin

USES:

Management of moderate to severe pain, chronic pain

Unlabeled uses:
Restless leg syndrome (RLS), postoperative shivering, arthralgia/myalgia, bone/dental/neuropathic pain

CONTRAINDICATIONS:

Hypersensitivity, acute intoxication with any CNS depressant, alcohol, asthma, respiratory depression

Precautions:
Pregnancy (C), breastfeeding, children, geriatric patients, seizure disorder, renal/hepatic disease, respiratory depression, head trauma, increased intracranial pressure, acute abdominal condition, drug abuse, depression, suicidal ideation

DOSAGE AND ROUTES
Calculator

Mild to moderate pain

• Adult:
PO
25 mg daily, titrate by 25 mg ≥3 days to 100 mg/day (25 mg qid), then may increase by 50 mg ≥3 days to 200 mg (50 mg qid), then 50-100 mg q4-6hr, max 400 mg/day, use caution in geriatric patients; orally disintegrating tab 50 mg/day, titrate by 50 mg q3day, separate doses to 200 mg/day (50 mg qid)

• Geriatric >75 years:
PO
<300 mg/day in divided doses

Moderate to severe chronic pain

• Adult:
PO-ER
(Ultram ER) 100 mg daily, titrate upward q5days in 100-mg increments, max 300 mg/day; (Ryzolt) 100 mg, titrate upward q2-3days in 100-mg increments, max 300 mg/day; products are not interchangeable

Renal dose

• Adult:
PO
CCr <30 ml/min, give q12hr, max 200 mg/day; do not use ext rel tab

Hepatic dose

• Adult (child-pugh c):
PO
50 mg q12hr, do not use ext rel tab

Restless leg syndrome (RLS) (unlabeled)

• Adult:
PO
50-150 mg/day × 15-24 mo

Available forms:
Tabs 50 mg; ext rel tab 100, 200, 300 mg; orally disinte
grating tab 50 mg; ext rel caps 100, 200, 300 mg

Administer:

•
Ext rel products
(Ryzolt/Utram ER) are not interchangeable

•
Do not break, crush, or chew ext rel product

•
With antiemetic for nausea, vomiting

•
When pain is beginning to return; determine dosage interval by patient response

•
With or without food; ER: always give with food, or always give on empty stomach

SIDE EFFECTS

CNS:
Dizziness, CNS stimulation, somnolence, headache, anxiety, confusion, euphoria,
seizures,
hallucinations, sedation,
neuroleptic-malignant-syndrome–like reactions

CV:
Vasodilation, orthostatic hypotension, tachycardia, hypertension, abnormal ECG

EENT:
Visual disturbances

GI:
Nausea, constipation, vomiting, dry mouth, diarrhea, abdominal pain, anorexia, flatulence,
GI bleeding

GU:
Urinary retention/frequency, menopausal symptoms, dysuria, menstrual disorder

INTEG:
Pruritus, rash, urticaria, vesicles, flushing

SYST:
Anaphylaxis, Stevens-Johnson syndrome, toxic epidermal necrolysis,
serotonin syndrome

PHARMACOKINETICS

Rapidly and almost completely absorbed, steady state 2 days, peak 1.5 hr, duration 6 hr, terminal half-life 7.9-8.8 hr, may cross blood-brain barrier, extensively metabolized, 30% excreted in urine as unchanged product, protein binding 20%

INTERACTIONS

•
Inhibition of norepinephrine and serotonin reuptake: MAOIs; use together with caution

Increase:
CNS depression—alcohol, sedatives, hypnotics, opiates

Increase:
serotonin syndrome—SSRIs, SNRIs, serotonin-receptor agonists

Increase:
traMADol levels—CYP3A4 inhibitors (aprepitant, antiretroviral protease inhibitors, clarithromycin, danazol, delavirdine, diltiazem, erythromycin, fluconazole, FLUoxetine, fluvoxaMINE, imatinib, ketoconazole, mibefradil, nefazodone, telithromycin, voriconazole)

Decrease:
traMADol effects—CYP3A4 inducers (barbiturates, bosentan, carBAMazepine, efavirenz, phenytoins, nevirapine, rifabutin, rifampin)

Decrease:
levels of traMADol—carBAMazepine

Drug/Herb

•
Avoid use with St. John’s wort

Increase:
CNS depression—chamomile, hops, kava, skullcap, valerian

Drug/Lab Test

Increase:
creatinine, hepatic enzymes

Decrease:
Hgb

NURSING CONSIDERATIONS

Assess:

•
Pain:
location, type, character, give before pain becomes extreme

•
Respiratory depression:
withhold if respirations <12/min

•
I&O ratio: check for decreasing output; may indicate urinary retention

•
Need for product; dependency

•
Bowel pattern; for constipation, increase fluids, bulk in diet

•
CNS changes: dizziness, drowsiness, hallucinations, euphoria, LOC, pupil reaction

•
Hypersensitivity:
usually after beginning treatment

•
Increased side effects in renal/hepatic disease

Serotonin syndrome, neuroleptic malignant syndrome:
increased heart rate, shivering, sweating, dilated pupils, tremors, high B/P, hyperthermia, headache, confusion; if these occur, stop product, administer serotonin antagonist if needed

Perform/provide:

•
Storage in cool environment, protected from sunlight

•
Assistance with ambulation

•
Safety measures: side rails, night-light, call bell within easy reach

Evaluate:

•
Therapeutic response: decrease in pain

Teach patient/family:

•
To report any symptoms of CNS changes, allergic reactions, serotonin syndrome, seizures

•
That drowsiness, dizziness, and confusion may occur; to avoid hazardous activities

•
To make position changes slowly because orthostatic hypotension may occur

•
To avoid OTC medications, herbs, supplements, CNS depressants and alcohol unless approved by prescriber

•
Not to discontinue abruptly, taper