VA/DoD CLINICAL PRACTICE GUIDELINE FOR OPIOID THERAPY FOR CHRONIC PAIN

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Short-Acting Opioid Initial Oral Dosage (in opioid-naïve) Additional Dosage Information Analgesic Onset (min) Peak (min) Duration (hr) N/A (rapid) 60 4 to 6 Dosing In Special Populations Other Considerations • Must NOT be taken concomitantly with alcohol which can increase serum tapentadol concentration • If used in combination with other CNS depressants, consider dose reduction of one or both agents • Use with or within 14 days of MAOIs is contraindicated Tapentadol • Available as 50, 75, or 100 mg tablets • 50 mg every 4 to 6 hr • Subsequent dose is 50, 75, or 100 mg every 4 to 6 hr, adjusted to analgesia and tolerability • Second dose may be given 1 hr after the first dose if necessary • Max recommended dose: 700 mg on first day, 600 mg on subsequent days • Use tapentadol only under careful medical supervision at lowest effective dose • Patients on LOT are likely to become tolerant 4 and require doses higher than the usual dosage range to maintain the desired effect • Elderly: Consider starting at the lowest recommended dose • Hepatic dysfunction: • Mild hepatic impairment: No dosage adjustment • Moderate hepatic impairment: Start at 50 mg and give subsequent doses at least 8 hr apart (max. 3 doses in 24 hr) • Severe hepatic impairment: Use is not recommended • Renal dysfunction: No dosage adjustment for mild or moderate renal impairment; not recommended in severe renal impairment • Respiratory dysfunction: Use with caution because of respiratory depressant effects; consider non–muopioid agonist analgesics February 2017 Page 86 of 192
Short-Acting Opioid Tramadol (alone or in combination with APAP) • Tramadol available as 50 mg tablet, or in tablet combination with APAP (325 mg APAP, 37.5 mg tramadol) Initial Oral Dosage (in opioid-naïve) • 25 mg every morning Additional Dosage Information • May increase by 25 mg per day every 3 days to 100 mg tramadol/d (25 mg every 6 hr) • Subsequent increments of 50 mg/d may then be made every 3 days to 200 mg/d (50 mg every 6 hr) • After titration, may give 50 to 100 mg every 4 to 6 hr • Maximum daily dose of tramadol: 400 mg/d • Combination product: maximum 4000 mg/d • APAP; 2000 mg/d APAP in chronic alcoholics or in hepatic impairment Analgesic Onset (min) Peak (min) Duration (hr) 75 years: give 30 ml/min: No change in dose or frequency required • CrCl
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DRAFT 3 - DO NOT DISTRIBUTE VA/DoD
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VA/DoD CLINICAL PRACTICE GUIDELINE FOR OPIOID THERAPY FOR CHRONIC PAIN

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