Tramadol/venlafaxine interaction
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Acute mania, withdrawal symptoms (unusual behaviour) following the omission of tramadol and intentional misuse of tramadol: case report A 49-year-old man developed acute mania following the concomitant administration of tramadol to control pain due to knee osteoarthritis and venlafaxine for major depressive disorder. Additionally, he developed withdrawal symptoms (unusual behaviour) following the omission of tramadol. He also self-increased his daily dose of tramadol (intentional drug misuse) due to poor pain control [routes, dosages and time to reactions onsets not stated]. The man had major depressive disorder, which was wellcontrolled with venlafaxine 75mg daily. He presented to the emergency department with his wife for agitation and confusion. He was then hospitalised. His wife reported that her husband had been prescribed tramadol at 50mg daily for knee osteoarthritis 1 month prior to admission but he (the husband) had self-increased tramadol to 150mg daily due to poor pain control. He ran out of tramadol 1 week prior to admission at which point he began to display unusual behavior, consistent with tramadol withdrawal symptoms. Additionally, his wife reported that her husband had stopped sleeping and had woken her multiple times in the middle of the night for seemingly random tasks such as reviewing their wedding photographs. The night before admission, her husband had screamed about the death of a long-dead loved one. He was also feeling confused. He was found to be tachycardic but was afebrile with no muscle rigidity or clonus on a physical examination. His urine drug analysis was found to be positive for opiates only. An ECG demonstrated atrial fibrillation and he was initiated on metoprolol following admission to the general medicine floor before psychiatry was consulted. On psychiatric evaluation, he was cooperative but had tangential with grandiose and religious delusions, as well as he had pressured speech. He displayed poor insight and resisted for his admission. He was diagnosed with acute mania. The man received treatment with olanzapine. He was found medically stable 4 days later and was transferred to the inpatient psychiatric ward for further monitoring. By the time of his transfer, he reported that his sleep had improved. Reevaluation on the day of transfer showed more organised speech without delusions, and he displayed no anxiety or agitation during his first group therapy session. It was decided to discontinue olanzapine, and he was observed for 2 days without medication before being deemed stable for discharge. At 4 month follow-up, he was feeling well off of the psychiatric medication, and reported no recurrent manic or depressive episodes. Author comment: "[W]e discuss a 49-year-old male . . . who developed . . . manic episode following use of tramadol." "SSRIs [are]. . .potent inhibitors of CYP2D6, the enzyme responsible for tramadol metabolism, while venlafaxine has relatively minimal inhibitory activity." "The patient’s wife reported that he ... had self-increased his daily dose
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