Unfortunately, NSAIDS do have many potential side-effects including the potential for creating stomach and small bowel ulceration, kidney dysfunction, liver damage, fluid retention and a small but real increased incidence of cardiovascular events.

So... a real dilemma for many clinicians is how to control arthritis pain in patients for whom NSAIDS have already caused problems or for patients who have the potential for developing problems.

One drug that has been used primarily for pain control is tramadol (Ultram). This is a drug that is a mild centrally acting narcotic drug with little addictive potential.

Tramadol is increasingly used for the treatment of osteoarthritis (OA) because it does not produce gastrointestinal bleeding or kidney problems and does not adversely affect cartilage, a controversial but possible side effect associated with NSAIDS.

A recent study sought to determine the analgesic effectiveness, the effect on physical function, the duration of benefit, and the safety of oral tramadol in patients with OA.

(Cepeda MS, et al. J Rheumatol. 2007; 34:543-545)
The scientists searched the Cochrane Central Register of Controlled Trials (Central), Medline, Embase, and Lilacs databases up to August 2005.

They included randomized controlled trials (RCT) that evaluated the effect of tramadol or tramadol plus paracetamol (equivalent to acetaminophen) on pain levels and/or physical function.

The researchers included 11 RCT with a total of 1019 participants who received tramadol or tramadol/paracetamol and 920 participants who received placebo or active control. Participants who received tramadol reported (1) less pain, a 12% relative decrease in pain intensity; (2) higher degree of global improvement: one of every 6 individuals taking tramadol or tramadol/paracetamol exhibited at least moderate global improvement; and (3) improvement in stiffness and function, than patients who received placebo. In terms of adverse events, one of every 5 participants who received tramadol or tramadol/paracetamol experienced minor adverse events and one of every eight stopped taking the medication because of adverse events compared to participants who received placebo.

Their conclusion was that tramadol or tramadol/paracetamol decreased pain intensity, produced symptom relief, and improved function in patients with OA, but these benefits were small.

In actual practice, tramadol is a drug that is often added to an NSAID for better pain control or used instead of an NSAID in high risk patients. As with most therapies, a patient's response is often dependent on the expectations of the physician.

Caution must be exercised when using tramadol.

First, particularly in older patients dosing must start at a low level, probably 25 mgs per day with a gradual increase as tolerated.

Second, there have been sporadic reports of increased risk of seizures in patients taking anti-depressant medicines such as selective serotonin reuptake inhibitors (SSRIs).

Tramadol should also be tapered when discontinued.

There are some potential drug interactions and these need to be evaluated.

A sustained release form of tramadol (Ultram ER) is now available in the U.S and appears to have a good tolerability profile.