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Approval Letter Issued for Orally-Disintegrating Tablet Version of Tramadol Hydrochloride
In March, Biovail filed a Complete Response to address routine matters raised in the Approvable Letter received from the FDA in early January. More specifically, these matters involved the resolution of labeling issues only, including, but not limited to, resolution of final packaging, content and format for the product's blister card and carton.
A 2004 study of the American population concluded that nearly 40% of adults have experienced problems with swallowing tablets - and a significant proportion of those fail to comply properly with their prescribed and ongoing dosage. Conditions such as post-procedural pain with swelling, associated with swallowing impairment, that require acute analgesic treatment, will benefit from the immediate orally dissolving tablet form.
How Tramadol ODT Works
Biovail's Tramadol ODT (tramadol hydrochloride orally disintegrating tablets) is a central acting analgesic in an orally disintegrating formulation using a Flashtab tablet formulation base. Although its mode of action is not completely understood, from animal tests, at least two complementary mechanisms appear applicable: binding of parent and M1 metabolite to u-opioid receptors and weak inhibition of reuptake of norepinephrine and serotonin. Tramadol has been shown to inhibit reuptake of norepinephrine and serotonin in vitro, as have some other opioid analgesics. These mechanisms may contribute independently to the overall profile of tramadol. Analgesia in humans begins approximately within one hour after administration and reaches a peak in approximately two or three hours.
According to labeling derived from its reference listed drug, Ultram, tramadol has been given in single oral doses of 50mg, 75mg and 100mg to patients with pain following surgical procedures and pain following oral surgery (extraction of impacted molars). In single-dose models of pain following oral surgery, pain relief was demonstrated in some patients at doses of 50mg and 75mg. A dose of 100mg tramadol tended to provide analgesia superior to codeine sulfate 60mg, but it was not as effective as the combination of aspirin 650mg with codeine phosphate 60mg.
Tramadol has been studied in three long-term controlled trials involving a total of 820 patients, with 530 patients receiving tramadol. Patients with a variety of chronic painful conditions were studied in double-blind trials of one to three months duration. Average daily doses of approximately 250mg of tramadol in divided doses were generally comparable to five doses of acetaminophen 300mg with codeine phosphate 30mg daily, five doses of aspirin 325mg with codeine phosphate 30mg daily, or two to three doses of acetaminophen 500mg with oxycodone hydrochloride 5mg daily.
In a randomized, blinded clinical study with 129 to 132 patients per group, a 10-day titration to a daily tramadol dose of 200mg (50mg q.i.d.), attained in 50mg increments every three days, was found to result in fewer discontinuations due to dizziness or vertigo than titration over only four days or no titration.
Tramadol ODT should not be administered to patients who have previously demonstrated hypersensitivity to tramadol, any other component of this product or opioids. Tramadol ODT is contraindicated in any situation where opioids are contraindicated, including acute intoxication with any of the following: alcohol, hypnotics, narcotics, centrally acting analgesics, opioids or psychotropic drugs. Tramadol ODT may worsen central nervous system and respiratory depression in these patients.
Seizures have been reported in patients receiving tramadol within the recommended dosage range. Spontaneous post-marketing reports indicate that seizure risk is increased with doses of tramadol above the recommended range. Concomitant use of tramadol increases the seizure risk in patients taking:
- Selective serotonin reuptake inhibitors (SSRI antidepressants or anorectics),
- Tricyclic antidepressants, and other tricyclic compounds (e.g., cyclobenzaprine, promethazine, etc.), or
- Opioid drugs.
Administration of tramadol may enhance the seizure risk in patients taking:
- MAO inhibitors,
- Neuroleptics, or
- Other drugs that reduce the seizure threshold.
Risk of convulsions may also increase in patients with epilepsy, those with a history of seizures, or in patients with a recognized risk for seizure (such as head trauma, metabolic disorders, alcohol and drug withdrawal, CNS infections). In tramadol overdose, naloxone administration may increase the risk of seizure.
Serious and rarely fatal anaphylactoid reactions have been reported in patients receiving therapy with tramadol. When these events do occur it is often following the first dose. Other reported allergic reactions include pruritus, hives, bronchospasm, angioedema, toxic epidermal necrolysis and Stevens-Johnson syndrome. Patients with a history of anaphylactoid reactions to codeine and other opioids may be at increased risk and therefore should not receive Tramadol ODT.
Tramadol is a centrally acting synthetic opioid analgesic, effective in the treatment of pain. Tramadol's minimal propensity to induce adverse effects is an advantage over morphine-like agents. Relative to morphine, tramadol causes less dependence and less respiratory depression.