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Dosage form: & nbspCapsules.
Composition:

1 capsule contains:

Active substance:

Tramadol hydrochloride 50.00 mg

Excipients:

Microcrystalline cellulose 54.00 mg


Carboxymethyl starch sodium 12.00 mg

Talc 3.00 mg

Magnesium stearate 1.00 mg

Composition of an empty gelatin capsule

Capsule body:

Gelatine 22.3440 mg

Titanium dioxide (E171) 0.4560 mg

Capsule cap:

Gelatine 14.8373 mg

Titanium dioxide (E171) 0.3040 mg

Crimson dye (Ponceau 4R) (E124) 0.0029 mg


Dye blue patented (E131)0.0200 mg


Black diamond dye (E151)0.0233 mg


Dye azorubin (E122) 0.0125 mg

Description:Two-color capsules number 4: capsule body white, cap capsule blue. The contents of the capsule are white or almost white powder.
Pharmacotherapeutic group:An analgesic with a mixed mechanism of action.
Pharmacodynamics:
Opioid synthetic analgesic, which has a central effect and action on the spinal cord (contributes to the discovery of potassium and calcium channels, causes hyperpolarization of membranes and inhibits pain impulses), enhances the action of sedative drugs. Activates opioid receptors (mu, delta, kappa) on the pre- and postsynaptic membranes of the afferent fibers of the nociceptive system in the brain and gastrointestinal tract (GI tract). Slows down the destruction of catecholamines, stabilizes their concentration in the central nervous system (CNS).
Tramadol is a racemic mixture of 2 enantiomers - dextrorotatory (+) and levorotatory (-), each of which exhibits a different receptor affinity.
The dextrorotatory enantiomer of tramadol is a selective agonist of mu-opioid receptors, and selectively inhibits the reverse neuronal capture of serotonin, while the levorotatory inhibits the reverse neuronal seizure of norepinephrine. Mono-O-desmethyltramadol (M1 metabolite) also selectively stimulates mu-opioid receptors.
The affinity of tramadol for opioid receptors is ten times weaker than that of codeine, and 6000 times weaker than morphine. Expression of analgesic action is 5-10 times weaker than morphine.
Analgesic effect is due to a decrease in nociceptive activity and an increase in the antinociceptive systems of the body.
Oppresses the respiratory center, excites the start zone of the vomiting center, the nucleus of the oculomotor nerve. With prolonged use, the development of tolerance is possible.
Pharmacokinetics:
Absorption - 90%, with oral bioavailability - 75% (increases with repeated use). Time to reach the maximum concentration (TCam) after oral administration - 2 h,Ml metabolite - 3 h.
Penetrates through blood-brain and placental barriers, 0.1% of tramadol is excreted in breast milk. The volume of distribution is 306 liters, the connection with plasma proteins is 20%.
In the liver, it is metabolized by N- and O-demethylation followed by conjugation with glucuronic acid. 11 metabolites have been identified, of which mono-O-desmethyltramadol (Ml) has pharmacological activity. The half-life (IVr) in the second phase is 6 h (tramadol), 7.9 h (mono-O-desmethyltramadol); in patients older than 75 years - 7.4 h (tramadol); with cirrhosis of the liver -13.3 ± 4.9 h (tramadol), 18.5 ± 9.4 h (mono-O-desmethyltramadol), in severe cases - 22.3 h and 36 h, respectively; with chronic renal failure (creatinine clearance (CK) less than 5 ml / min) - 11 ± 3.2 h (tramadol), 16.9 ± 3 h (mono-O-desmethyltramadol), in severe cases - 19.5 h and 43.2 h, respectively. It is excreted by the kidneys (25-35% unchanged), the average cumulative index of renal excretion is 94%. About 7% is excreted by hemodialysis.
Indications:
- pain syndrome of strong and moderate intensity of different etiology (including trauma, postoperative period, pain in cancer patients);

- anesthesia in the conduct of painful diagnostic and therapeutic manipulations.
Contraindications:
-increased sensitivity to tramadol and other analgesics; -States accompanied by respiratory depression or severe CNS depression (including alcohol poisoning, hypnotic JIC, narcotic analgesics and other psychoactive JIC);
-pharmacoresistance epilepsy;
-generous renal and / or hepatic insufficiency (CC less than 10 ml / min);
- The use of tramadol as a drug for the treatment of the syndrome of "withdrawal" of drugs;
-Children's age (up to 14 years);
- simultaneous application of monoamine oxidase inhibitors (MAO) and within 14 days after their cancellation;
- suicidal tendencies, propensity to abuse of psychoactive substances;
pregnancy, lactation period (during pregnancy and during breastfeeding, the application is only possible according to vital indications).
Carefully:Impaired renal function (QC 10-30 ml / min) and / or liver, craniocerebral trauma, disorders of consciousness of different genesis, convulsions, intracranial hypertension, epilepsy, abdominal pain of unclear genesis ("acute" abdomen), simultaneous use with selective serotonin reuptake inhibitors (some antidepressants and drugs that reduce appetite), tricyclic antidepressants,other tricyclic compounds (for example, prometazine), antimigrenous drugs (triptans), narcotic analgesics, neuroleptics, etc. LS, reducing the threshold of convulsive activity; propensity to form addiction (alcoholism, drug or drug dependence).
Pregnancy and lactation:
Safety of use during pregnancy is not established. High doses can have adverse effects on the fetus and the newborn. The application is possible only under the strictest medical supervision and in individual, exceptional cases, if the potential benefit to the mother justifies the risk to the child.
It should be borne in mind that during lactation approximately 0.1% of the dose of the drug is secreted into breast milk.
During pregnancy and during breastfeeding, the drug Tramadol it is possible only for vital indications.
Dosing and Administration:

Inside. The dose depends on the severity of the pain syndrome and the individual sensitivity of the patient. The time of taking the drug does not depend on the time of eating. Adults and adolescents over 14 years of age

Single dose - 50 mg (1 capsule).In the absence of an analgesic effect after 30-60 minutes, another 1 capsule of tramadol can be taken again. With pain of strong intensity, a single dose of -100 mg (2 capsules of 50 mg).

The analgesic effect is usually maintained for 4-8 hours. The maximum daily dose is 400 mg.

Patients with impaired renal / hepatic function

In patients with impaired renal and / or liver function tramadol can last longer due to possible lengthening T1/2. For such patients, the doctor may recommend an increase in the interval between taking single doses. With QC less than 30 ml / min and in patients with hepatic insufficiency, an interval of 12 hours between taking the next doses of the drug Tramadol.

The maximum daily dose for patients with impaired renal function should not exceed 200 mg (4 capsules of 50 mg).

Patients on hemodialysis are given regular doses of the drug Tramadol even on dialysis day.

Patients with cirrhosis are recommended to 50 mg (1 capsule) every 12 hours (2 capsules per day).

Patients older than 75 years

In patients older than 75 years, the excretion of tramadol is slowed from the body, even when there are no clinical manifestations of renal and / or hepatic impairment.These patients also need to increase the interval between taking the drug.

Do not exceed the daily dose of 300 mg (6 capsules of 50 mg).

Side effects:

Classification of the incidence of adverse events (WHO):

very often> 1/10

often from> 1/100 to <1/10

infrequently from> 1/1000 to <1/100

rarely from> 1/10000 to <1/1000

very rarely from <1/10000, including individual messages.

From the central and peripheral nervous system:

Often: dizziness;

Often: headache;

Infrequently: anxiety, confusion, drowsiness;

Rarely: euphoria, emotional instability, nightmares, cognitive disorders, hallucinations, amnesia; disorders of coordination of movements, convulsions, paresthesia, tremor, impaired concentration, epileptiform seizures, with prolonged use - the development of drug dependence;

Rarely: panic attacks, ringing in the ears;

From the cardiovascular system:

Rarely: tachycardia, palpitations, cardiovascular collapse, fainting,

orthostatic hypotension, cardiovascular failure;

Rarely: bradycardia, increased blood pressure;

From the respiratory system:

Rarely: shortness of breath, respiratory depression, pulmonary edema;

From the sense organs:

Rarely: decreased visual acuity, sometimes mydriasis, a taste disorder;

From the digestive system:

Often: nausea;

Often: vomiting, constipation or diarrhea, dryness of the oral mucosa;

Infrequently: dyspepsia, abdominal pain, bloating;

Rarely: difficulty in swallowing;

Rarely: increased activity of "liver" transaminases;

From the skin:

Often: sweating;

From the genitourinary system:

Infrequently: urinary retention, increased frequency of urination, menstrual irregularity, signs of menopause;

Rarely: dysuria;

From the musculoskeletal system:

Rarely: muscle weakness;

From the side of metabolism:

Infrequently: anorexia;

Rarely: decreased body weight;

Allergic reactions:

Rarely: allergic reactions (eg urticaria, pruritus, exanthema, bullous rash, angioedema) and anaphylaxis, which can cause azole dyes E122, E124 and E151.

Other: with prolonged use - drug dependence; with a sharp abolition - the "cancellation" syndrome.

Overdose:

Symptoms: disorders of consciousness (up to coma), cramps, lowering blood pressure, tachycardia, narrowing or dilating pupils, respiratory depression;

Treatment: with severe intoxication with loss of consciousness and superficial, weak breathing, it is necessary to introduce antagonists, opioid receptors (naloxone), and with cerebral convulsions - preparations of benzodiazepine series (diazepam), intravenously. Hemodialysis is ineffective. Excretion of tramadol by hemodialysis is about 7%.

Interaction:
Tramadol can not be used concomitantly with MAO inhibitors or within 2 weeks after they are discontinued.
With the simultaneous use of substances acting on the central nervous system (anesthetics, antidepressants, antipsychotics, sedatives, anxiolytics, hypnotics) or with the use of alcohol, there is a possibility of a synergistic effect, manifested by excessive sedation and increased analgesic effect.
Tramadol enhances the action of JIC, depressing the central nervous system, and ethanol.
Inductors of microsomal oxidation (incl. carbamazepine, barbiturates) reduce the severity of the analgesic effect and the duration of the action.Due to the increased risk of seizures, the simultaneous use of carbamazepine and tramadol is not recommended.
Long-term use of opioid analgesics or barbiturates stimulates the development of cross tolerance.
Anxiolytics increase the severity of the analgesic effect; The duration of anesthesia increases with combination with barbiturates.
Naloxone activates breathing, eliminating analgesia after the use of opioid analgesics.
MAO inhibitors, furazolidone, procarbazine, antipsychotic drugs (neuroleptics) increase the risk of seizures (reduction of the convulsive threshold).
Quinidine increases the plasma concentration of tramadol and reduces the M1 metabolite at the expense of a competitive inhibition isoenzyme CYP2D6.
Inhibitors of the CYP2D6 isoenzyme (such as fluoxetine, paroxetine and amitriptyline) reduce the metabolism of tramadol.
Selective serotonin reuptake inhibitors (some antidepressants and JIC, which reduce appetite), tricyclic antidepressants, other tricyclic compounds (for example, promethazine), antimigrenous JIC (triptans), narcotic analgesics, MAO inhibitors, neuroleptics, and others.JIC, reducing the threshold of convulsive readiness, increase the risk of seizures.
Selective serotonin reuptake inhibitors, serotonin reuptake inhibitors and norepinephrine, tricyclic antidepressants, MAO inhibitors, antimigrenous JICs (triptans), and JICs that disrupt the metabolism of tramadol (inhibitors of CYP2D6 and CYP3A4 isoenzymes), when combined with tramadol, can cause serotonin syndrome (confusion , agitation, hyperthermia, sweating, ataxia, hyperreflexia, myoclonus, diarrhea). The abolition of serotonergic drugs causes rapid relief of the symptoms of serotonin syndrome.
Caution should be exercised with simultaneous therapy with tramadol and coumarin derivatives (eg, warfarin), since there are reports of an increase in the international normalized ratio (MHO) and the appearance of ecchymoses in some patients.
Pre- or post-operative use of an anti-emetic agent, a 5-HTZ-serotonin receptor antagonist, increases the need for tramadol in patients with postoperative pain syndrome.
Special instructions:
Tramadol can be used in patients with hypersensitivity to opioids, but with great caution.
Tramadol should be avoided for those who are addicted to addiction (alcoholism, drug or drug dependence). With the use of tramadol, the risk of suicide increases.
With the development of severe adverse effects should stop taking the drug.
Patients with cerebral cramps should remain under careful medical supervision during drug treatment and within a few days after discontinuation.
Tramadol is not suitable as a substitute therapy for opioid dependence. In patients with impaired liver function due to reduced hepatic clearance, the concentration of tramadol in the blood serum increases and its T1 / 2 increases. Such patients are recommended smaller doses and / or an increase in intervals between drug intake Tramadol.
Tramadol can, but with great caution, be used in patients with elevated intracranial pressure and a traumatic brain injury in the anamnesis.
The azole dyes E122, E124 and E151 in susceptible people can cause reactions
allergic type, including those with signs of anaphylaxis and bronchospasm, especially in
persons with bronchial asthma or allergic diseases in the anamnesis.
Effect on the ability to drive transp. cf. and fur:A drug Tramadol can cause a violation of concentration of attention, hallucinations, confusion, dizziness and other side effects, so during treatment with the drug should refrain from driving and other potentially dangerous activities that require increased concentration and speed of psychomotor reactions.
Form release / dosage:
Capsules 50 mg.

Packaging:
10 capsules per blister.
2 blisters in a pack of cardboard along with instructions for use.
Storage conditions:At temperatures not higher than 30 ° C, in the original packaging. Keep out of the reach of children.
The drug belongs to the list of No. 1 potent substances of the Standing Committee on Drug Control of the Ministry of Health and Social Development.
Shelf life:5 years. Do not use the drug after the expiration date.
Terms of leave from pharmacies:On prescription
Registration number:П N012155 / 01
Date of registration:22.12.2010
The owner of the registration certificate:KRKA, dd, Novo mesto, AOKRKA, dd, Novo mesto, AO
Manufacturer: & nbsp
KRKA, d.d. Slovenia
Representation: & nbspKRKA, dd, Novo mesto, AOKRKA, dd, Novo mesto, AO
Information update date: & nbsp14.09.2015
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