Tramadol Relieves Neuropathic Pain

Clinical Question

Is tramadol (Ultram) safe and effective for the treatment of neuropathic pain?

Evidence-Based Answer

Tramadol is an effective treatment for neuropathic pain. One out of four patients who take the medication achieves at least 50 percent pain relief.

Practice Pointers

Tramadol is a unique pain reliever that is thought to work via a weak effect on opioid receptors and by limiting reuptake of serotonin and norepinephrine, an effect occurring with many antidepressants. This systematic review identified six randomized controlled trials of tramadol for the treatment of neuropathic pain. Four studies (337 total patients) compared tramadol with placebo. All four studies were double-blinded, and three of the four studies (including 302 of the patients) adequately concealed allocation from participants and accounted for patients lost to follow-up.

The review found a clinically significant benefit with tramadol (number needed to treat to achieve at least 50 percent pain relief = 3.8; 95% confidence interval [CI], 2.8 to 6.3). One small, unblinded study (21 total patients) found no difference between tramadol and clomipramine (Anafranil). Another study (40 total patients) found no clear difference between tramadol and morphine in patients with cancer-related pain. However, these studies were too small and too poorly designed (i.e., unblinded with many dropouts) to draw firm conclusions.

Between 5 and 15 percent of patients discontinued the study medication because of adverse effects. In the two studies that provided adverse effects data, the combined number needed to harm was 7.7 (95% CI, 4.6 to 20). Although no life-threatening adverse effects were reported, tramadol can lower the seizure threshold and should not be given to patients with a history of seizure. An evidence-based guideline from the Institute for Clinical Systems Improvement recommends tramadol as a treatment option for neuropathic pain,1 and an expert panel recommends it as a first-line treatment.2

Nonpharmacologic vs. Anticholinergic Therapies for Overactive Bladder

Clinical Question

How do nonpharmacologic therapies compare with anticholinergic medications in patients with overactive bladder (i.e., urinary urgency)?

Evidence-Based Answer

Anticholinergic medications are more effective than bladder training in reducing the number of voids per day. Combining an anti-cholinergic medication with bladder training is more effective than either therapy alone.

Practice Pointers

Overactive bladder can be associated with urge incontinence, urinary frequency, and nocturia. Causes of chronic bladder irritation include urinary tract infection; pelvic surgery; estrogen deficiency; diabetes; multiple sclerosis; medications (e.g., neuroleptics, diuretics); cerebral ischemia; dementia; and overflow incontinence.1

The most common treatments for overactive bladder are anticholinergic medications, bladder training, pelvic floor muscle training, biofeedback, and electric stimulation of the detrusor muscles. Compared with placebo, persons taking anticholinergic medications for overactive bladder have about five fewer trips to the bathroom and four fewer leakage episodes per week. Patients taking anticholinergic medications also report modest improvements in quality of life.2

This Cochrane review included randomized or quasirandomized controlled trials that compared anticholinergic medications with nonpharmacologic therapies for overactive bladder or urinary urge incontinence in adults. Thirteen trials (1,770 total participants treated for three to 12 weeks) were identified; however, most trials were small and protocols varied, making it difficult to draw many firm conclusions.

Bladder training was the most effective non-pharmacologic treatment studied. Six trials (288 total participants) compared anticholinergic medications (4 mg of tolterodine [Detrol], 45 mg of propantheline [Pro-Banthine], or 5 to 45 mg of oxybutynin [Ditropan] daily). Overall, anticholinergic medications improved symptoms compared with bladder training alone (relative risk = 0.73; 95% confidence interval, 0.59 to 0.90). Combining bladder training with an anticholinergic medication improved symptoms compared with either treatment alone. Patients receiving combined treatment had about 5 percent fewer voids per day, and about 15 percent of patients reported a greater change from baseline in the sensation of urgency.

No trials of pelvic floor muscle training or surgery were found. No significant difference between anticholinergic medications and electrostimulation was found. About one third of patients taking anticholinergic medications experienced adverse effects such as dry mouth, headache, constipation, dizziness, decreased visual acuity, and tachycardia.