U.S. patent application number 16/926389 was filed with the patent office on 2020-10-29 for intravenous administration of tramadol.
This patent application is currently assigned to Revogenex Ireland Ltd. The applicant listed for this patent is Revogenex Ireland Ltd. Invention is credited to Lucy Lu.
Application Number | 20200337988 16/926389 |
Document ID | / |
Family ID | 1000004946155 |
Filed Date | 2020-10-29 |
![](/patent/app/20200337988/US20200337988A1-20201029-C00001.png)
![](/patent/app/20200337988/US20200337988A1-20201029-C00002.png)
United States Patent
Application |
20200337988 |
Kind Code |
A1 |
Lu; Lucy |
October 29, 2020 |
INTRAVENOUS ADMINISTRATION OF TRAMADOL
Abstract
A method of treating pain, e.g., acute post-operative pain, by
intravenously administering to a human patient(s) a dose of
tramadol of about 45 mg to about 80 mg, based on tramadol
hydrochloride, together with an intravenous dose of a
therapeutically effective amount of ketorolac about every 6
hours.
Inventors: |
Lu; Lucy; (New York,
NY) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
Revogenex Ireland Ltd |
Dublin 6 |
|
IE |
|
|
Assignee: |
Revogenex Ireland Ltd
Dublin 6
IE
|
Family ID: |
1000004946155 |
Appl. No.: |
16/926389 |
Filed: |
July 10, 2020 |
Related U.S. Patent Documents
|
|
|
|
|
|
Application
Number |
Filing Date |
Patent Number |
|
|
16376382 |
Apr 5, 2019 |
10729645 |
|
|
16926389 |
|
|
|
|
16269213 |
Feb 6, 2019 |
10751279 |
|
|
16376382 |
|
|
|
|
16223556 |
Dec 18, 2018 |
10646433 |
|
|
16269213 |
|
|
|
|
15976503 |
May 10, 2018 |
10751277 |
|
|
16223556 |
|
|
|
|
15612665 |
Jun 2, 2017 |
9968551 |
|
|
15976503 |
|
|
|
|
15163111 |
May 24, 2016 |
9693949 |
|
|
15612665 |
|
|
|
|
62804518 |
Feb 12, 2019 |
|
|
|
62271107 |
Dec 22, 2015 |
|
|
|
Current U.S.
Class: |
1/1 |
Current CPC
Class: |
A61K 31/135 20130101;
A61K 9/0053 20130101; A61P 25/04 20180101; A61K 31/138 20130101;
A61K 9/0019 20130101; A61P 25/00 20180101 |
International
Class: |
A61K 9/00 20060101
A61K009/00; A61K 31/135 20060101 A61K031/135; A61K 31/138 20060101
A61K031/138 |
Claims
1. A method of administering tramadol for treating pain via an
intravenous dosing regimen, comprising intravenously administering
a first dose of tramadol to a human patient in an amount from about
45 mg to about 80 mg; and concurrently administering an intravenous
dose of ketorolac or a pharmaceutically acceptable salt thereof in
an amount from about 10 mg to about 30 mg; and thereafter
intravenously administering the doses of tramadol and ketorolac
about every 6 hours until the patient no longer requires treatment
with intravenous tramadol, wherein the tramadol is tramadol base or
a pharmaceutically acceptable salt of tramadol.
2. The method of claim 1, wherein the intravenous dosing regimen
provides a Cmax of tramadol which is similar to the Cmax of an oral
dose of 100 mg tramadol HCl given every 6 hours at
steady-state.
3. The method of claim 1, wherein each dose of tramadol is about 60
mg tramadol hydrochloride.
4. The method of claim 3, the intravenous dosing regimen of the
invention provide a Cmax of tramadol at steady-state that is from
about 80% to about 125% of the Cmax provided at steady-state by a
100 mg oral dose of tramadol HCl given every 6 hours.
5. The method of claim 3, wherein the intravenous dosing regimen
provides a Cmax of tramadol at steady-state from about 80% to about
125% of about 736 ng/mL.
6. The method of claim 1, further comprising continuing to
administer additional doses of tramadol and ketorolac to the human
patient for at least about 42 hours after the first administered
dose of tramadol.
7. The method of claim 1, further comprising diluting the dose of
tramadol and ketorolac in from about 50 ml to about 500 ml of a
pharmaceutically acceptable fluid for injection, and standardizing
the administration of the injection of the dose of tramadol and
ketorolac via the use of a pump.
8. The method of claim 7, wherein the dose is provided in the form
of a sterile solution at a concentration of about 60 mg tramadol
hydrochloride and from about 10 mg to about 30 ketorolac
tromethamine contained in one or more ampoules.
9. The method of claim 8, wherein the ampoules contain the dose of
tramadol together ketorolac with a buffering agent in a carrier
comprising water for injection.
10. The method of claim 1, wherein the dose of tramadol is
administered intravenously over a time period from about 2 to about
20 minutes and the ketorolac is administered as an IV push
separately although concomitantly.
11. The method of claim 1, further comprising diluting the dose of
tramadol and ketorolac into an IV bag for administration to the
human patient.
12. The method of claim 1 wherein the patient is undergoing
surgery, further comprising administering a first dose of
tramadol/ketorolac to the patient intra-operatively at wound
closure, or from first demand of analgesia postoperatively, and
administering further doses of intravenous tramadol/ketorolac for
at least two days post-surgery.
13. The method of claim 1, wherein the human patient is suffering
from acute post-operative pain.
14. The method of claim 13, further comprising switching the human
patient after at least three intravenous doses of
tramadol/ketorolac, to oral doses of the same amount of tramadol
and acetaminophen previously administered intravenously, such that
the Cmax of tramadol at the time the human patient is switched to
oral doses is similar to the Cmax provided at steady-state by a
dosing regimen of 100 mg tramadol HCl administered orally every 6
hours.
15. The method of claim 1, further comprising administering an
opioid analgesic which is not tramadol to the human patient to
treat breakthrough pain.
16. A method of administering tramadol for treating pain via an
intravenous dosing regimen, comprising intravenously administering
a first dose of tramadol to a human patient in an amount of about
60 mg; and concurrently administering an intravenous dose of
ketorolac tromethamine in an amount of about 10 mg to about 30 mg;
and thereafter intravenously administering the doses of tramadol
and acetaminophen about every 6 hours until the patient no longer
requires treatment with intravenous tramadol, wherein the tramadol
is tramadol base or a pharmaceutically acceptable salt of tramadol,
such that the intravenous dosing regimen provides a Cmax of
tramadol which is similar to the Cmax of an oral dose of 100 mg
tramadol HCl given every 6 hours at steady-state.
17. The method of claim 16, the intravenous dosing regimen of the
invention provide a Cmax of tramadol at steady-state that is from
about 80% to about 125% of the Cmax provided at steady-state by a
100 mg oral dose of tramadol HCl given every 6 hours.
18. The method of claim 16, wherein the intravenous dosing regimen
provides a Cmax of tramadol at steady-state from about 80% to about
125% of about 736 ng/mL.
19. A kit, comprising a vial containing an intravenous dose of
tramadol or a pharmaceutically acceptable salt thereof in an amount
from about 45 mg to about 80 mg (based on the hydrochloride salt);
and a vial containing an intravenous dose of ketorolac tromethamine
in an amount from about 10 mg to about 30 mg.
20. The kit of claim 19, which contains additional doses of
tramadol and ketorolac tromethamine.
Description
BACKGROUND OF THE INVENTION
[0001] Tramadol is a centrally acting synthetic analgesic with a
dual mechanism of action attributed to the racemic form of the
drug, comprised of .mu.-opioid activity (binding to .mu.-opioid
receptors and monoamine (serotonin and noradrenalin) reuptake
inhibition. Tramadol is an analog of the phenanthrene group of
opium alkaloids, which includes morphine and codeine, and is
structurally related to these opioids (Grond S and Slabotzi A.
Clinical pharmacology of tramadol. Clin Pharmacokinet.
2004;43:879-923). Like codeine, there is a substitution of the
methyl group on the phenol ring that imparts a relatively weak
affinity for opioid receptors. (+)-Tramadol is a more potent
inhibitor of serotonin uptake, while (-)-tramadol is a more potent
inhibitor of norepinephrine uptake. The opioid-like activity of
tramadol derives from low affinity binding of the parent compound
to .mu.-opioid receptors and higher affinity binding of its main
metabolite. Tramadol affinity to .mu. opioid receptors is about 10
times weaker than codeine 60 times weaker than dextropropoxyphene
and 6,000 times weaker than morphine. The active metabolite
O-desmethyltramadol (M1) possesses a higher affinity to the .mu.
opioid receptor than tramadol and displays analgesic activity
(Leppert W, 2009).
[0002] Tramadol was originally developed by the German
pharmaceutical company Grunenthal GmbH in the late 1970s and is
marketed globally under the trade names TRAMAL.RTM. and others
outside of the United States. The approved doses of tramadol are 50
mg or 100 mg administered as a slow injection every 4-6 hours
(Tramadol Core Product Label, 2008). In the U.S., tramadol is
approved by the Food and Drug Administration (FDA) and marketed as
an oral capsule/tablet for moderate to moderately severe pain in
adults. Tramadol was first approved in the US in April 1995 under
the trade name, ULTRAM.RTM. (Ortho-McNeil-Janssen Pharmaceuticals,
Inc). Tramadol is also an active agent in an extended release
product, Ultram.RTM. ER, and a combination product with
acetaminophen, ULTRACET.RTM.. In the US, tramadol is only available
as immediate release tablets or extended release tablets. Other
tramadol formulations approved in several countries include
tablets, capsules, effervescent powders, and suppositories (Grond
and Sablotzki, 2004; Rosenberg, 2009). The approved intravenous
regimen in India is an initial injection of 50 mg infusion over 2-3
min, followed by 50 mg every 10-20 minutes if necessary up to 250
mg for the first hour. Maintenance doses are 50-100 mg every 4-6
hours with a maximum dose of 600 mg daily (Tramadol, CIMS
Data_India).
[0003] Postoperative pain management with tramadol has effectively
utilized a variety of delivery methods, including bolus injection
(IV or IM), continuous infusions and patient controlled analgesia
(PCA) pumps, and various combinations of these methods (Scott and
Perry, 2000; Grond and Sablotzki, 2004). The potency ratio of IV
tramadol to IV morphine is approximately 1:10, while the ratio for
IV fentanyl is 1:979 (Grond and Sablotzki, 2004).
[0004] The "on-demand" analgesic efficacy of tramadol was compared
to morphine in the 24-hour post-operative period for 523 patients
undergoing abdominal surgery (Vickers M D, Paravicini D. Comparison
of tramadol with morphine for post-operative pain following
abdominal surgery. Eur J Anesthesiol. 1995;12: 265-71). Patients
who reported post-operative pain received an initial dose (either
tramadol 100 mg or morphine 5 mg i.v.) and, if necessary, repeat
i.v. or i.m. doses of tramadol 50 mg or morphine 5 mg on demand
over the first 90 minutes. Further doses up to a total of 400 mg
tramadol or 40 mg morphine could then be given after 90 minutes up
to 24 hours after the first dose of study medication. The primary
efficacy parameter was the responder rate (no or slight pain)
within the first 90 minutes of treatment. Responder rates were
72.6% for tramadol and 81.2% for morphine, which were statistically
equivalent and within the predefined range of.+-.10%. Mean
cumulative doses were 188.2 mg for the first 90 minutes and 157.1
mg for the subsequent 22.5 hours in the tramadol group and 13.9 mg
and 18.4 mg, respectively in the morphine group. The main adverse
events were gastrointestinal in both groups, with mild nausea, dry
mouth, vomiting, dyspepsia and hiccups reported most
frequently.
[0005] The analgesic effect of continuous infusion of tramadol was
compared to repeated bolus administration in 135 patients
undergoing abdominal surgery (Rud U, Fischer M V, Mewes R,
Paravcini D., " Postoperative Analgesie mit Tramadol
Kontinuierliche Infusion versus repetitive" (Postoperative
analgesia with tramadol. Continuous infusion versus repetitive
bolus administration), Bolusgabe Anaesthesist. 1994;43:316-321.
(German)). Patients were randomized at the time of the first
request for pain treatment. All patients received a loading dose of
tramadol 100 mg i.v. Subsequent treatment was administered in a
double-blind manner; patients in the infusion group were given a
continuous infusion of tramadol 12 mg/h for 24 hours, whereas
patients in the bolus group received placebo infusion. In both
groups, additional bolus doses of tramadol 50 mg i.v. were given as
required. Pain relief was monitored by means of a visual analog
scale (VAS) up to 6 hours after surgery. The number of additional
boluses and the amount of tramadol administered at 6 hours and 24
hours was also used to assess analgesic efficacy. More patients in
the infusion group assessed their pain relief as excellent or good
compared to the bolus group (76.5% vs 65.6%). Only a few patients
complained of insufficient analgesia, with more patients in the
bolus group reporting inadequate pain relief than in the infusion
group (7.5% vs 4.4%). A higher percentage of patients in the bolus
group required two or more boluses compared to the infusion group
(59.7% vs 30.8%). After 6 hours, the average tramadol consumption
was 223.5.+-.53.7 mg in the infusion group and 176.6.+-.63.1 mg in
the bolus group (p<0.05). After 24 hours, tramadol consumption
was 449.5.+-.66.0 mg and 201.6.+-.83.9 mg (p<0.001),
respectively. Adverse events were reported by 25% of patients in
both groups, with no significant differences and no patient
terminated the trial for an adverse event. There were no
significant effects on blood pressure or heart rate. The authors
concluded that continuous infusion was more effective in the first
6 hours after surgery. However, excess consumption by the infusion
group was statistically greater than the bolus group at both 6
hours and 24 hours post-surgery.
[0006] Intermittent bolus and continuous infusion of tramadol were
evaluated in a postoperative study of 35 patients undergoing major
abdominal gynecologic surgery (Chrubasik J, Buzina M,
Schulte-Monting J, Atanassoff P, Alon E. Intravenous tramadol for
post-operative pain -comparison of intermittent dose regimens with
and without maintenance infusion. Eur J Anaesthesiol.
1992;9:23-28). The study was randomized and double-blind and used
tramadol infusion 15 mg/h or saline. Additional boluses of tramadol
100 mg were given as requested. The patients in the infusion group
required 60% less tramadol on demand (p<0.01) and had better
pain relief (p<0.05), as assessed by VAS, than the group that
received the saline infusion. Total tramadol consumption, however,
was about 30% higher in the infusion group (p<0.05) and was
associated with and increased incidence of minor adverse events.
Tramadol was ineffective as pain relief within 2 hours of the
beginning of treatment in 6% of the infusion group and 20% of the
bolus group. Thus, continuous infusion was preferred to "on-demand"
bolus treatment.
[0007] A meta-analysis of nine randomized, controlled trials
indicated that tramadol was as effective as other opioids,
including morphine, for control of postoperative pain (Scott and
Perry, 2000). Pain in these patients was described as moderate to
severe, with initial postoperative pain reported as >60 on a
100-point visual analog scale or as moderate or severe on a 4- or
5-point verbal response scale. The first dose of analgesia was
administered when patients reported moderate to severe pain in the
postoperative setting. Studies that did not adequately record
baseline pain severity or response to analgesia, were not
randomized or controlled or contained less than 45 patients were
excluded from the meta-analysis. Tramadol, administered in a dose
titrated to pain response and via either IV (intravenous) or IM
(intramuscular) intermittent injection, reduced pain intensity by
46.8% to 57.6% after 4 to 6 hours compared to 69.8% for morphine
and 25.6% to 51.3% for pentazocine. Efficacy of tramadol was
maintained for the duration of the studies, which were <72
hours, and was comparable to morphine or alfentanil. However, the
onset of action of tramadol was slower than morphine, as assessed
by measurements approximately 3 hours after the first dose. There
were no significant differences in the percentage of patients
treated with tramadol or morphine and who also required rescue
medication. The patient global response and physician global
response were similar for tramadol and for other opioids.
[0008] Tramadol injection (IV/IM/SC) is approved and used for the
management of moderate to severe acute postoperative pain in
several regions, including Europe, India and Australia/New Zealand
(however, this dosage form is not available in the USA). Tramadol
ampoules or vials for IV, IM and SC administration and
preservative-free solutions for injection by the various spinal
routes (epidural, intrathecal, caudal, etc.) are available forms in
these regions. Tramadol formulations approved in several countries
include, tablets, capsules, effervescent powders, and suppositories
(Grond and Sablotzki, 2004; Rosenberg, 2009).
[0009] There is extensive data demonstrating that tramadol use is
not associated with the classical opioid side effects seen with
more potent opioids. There are numerous reports of the safety and
efficacy of tramadol (Lee et al., 1993; Scott and Perry, 2000;
Grond and Sablotzki, 2004). The most common adverse events of
tramadol administration are nausea, dizziness, headache,
somnolence, sweating, fatigue, constipation, dry mouth and
vomiting. However, tramadol use, particularly with high doses, has
been associated with seizures, and the risk of seizures is
increased in the presence of drugs that reduce seizure threshold,
head trauma or prior history of seizures.
[0010] Patients undergoing surgery, for example, total knee
arthroplasty (TKA) and total hip arthroplasty (THA), typically
demonstrate a need for short-term analgesia, which is critical for
earlier mobilization and rehabilitation. In this setting, assuring
adequate pain relief without providing extensive medical oversight
required for some methods of treatment (such as neuraxial
anesthesia) and prevention of effects such as opiate-induced
respiratory depression and dependency would be highly beneficial
(Sinatra et al., 2002).
[0011] The goal of post-surgical pain management is twofold: i) to
provide a quick onset of analgesic or pain relief and ii) to reduce
or modulate the quality and intensity of pain that a patient
experiences in the post-surgical period. While current treatments
for management of post-surgical acute pain are useful, there is a
need for improved methods for treating post-surgical acute
pain.
[0012] Prior publications report that analgesic potency may be
improved while reducing undesirable effects by combining an opioid
with an NSAID or an analgesic such as acetylsalicylic acid or
acetaminophen, in such a way as to obtain a synergistic analgesic
effect allowing for a reduction in the total dose of both the NSAID
and analgesic. For example, U.S. Pat. No. 4,569,937, issued to
Baker et al. on Feb. 11, 1986, describes a combination of oxycodone
with ibuprofen in a ratio of oxycodone/ibuprofen from 1:6 to about
1:400. U.S. Pat. No. 4,690,927, issued to Voss et al. on Sep. 1,
1987, describes a combination of the NSAID diclofenac and codeine
in a weight ratio of diclofenac to codeine of about 1:1 to about
3:1. U.S. Pat. No. 5,190,947, issued to Riess et al. on Mar. 2,
1993, describes a diclofenac-codeine salt
([2-[2,6-dichlorophenyl)-amino]-phenyl]-acetic acid). U.S. Pat. No.
4,844,907, issued to Elger et al. on Jul. 4, 1989, describes a
multiphase tablet combining a narcotic analgesic phase and an NSAID
phase in separate layers. U.S. Pat. No. 4,587,252, issued to Arnold
et al. on May 6, 1986, describes a process for treating pain using
a combination of hydrocodone and ibuprofen.
OBJECTS AND SUMMARY OF THE INVENTION
[0013] It is an object of the present invention to provide a method
of treating pain in human patients.
[0014] It is a further object of the present invention to provide a
method of treating pain in human patients who are unable to take
oral medications, such as in a post-operative condition.
[0015] It is a further object of the present invention to provide a
method of treating pain in human patients that takes advantage of
the faster onset of intravenous administration of tramadol while
providing additional benefits not available via current
methodologies of tramadol intravenous administration.
[0016] It is another object of the present invention to provide a
method of providing a safe and effective alternative injectable
analgesic for use in the acute postoperative setting.
[0017] It is another object of the present invention to provide a
method for treating pain in, e.g., the acute postoperative setting
which is or may be opioid-sparing.
[0018] It is another object of the present invention to provide a
method for treating pain with intravenous tramadol in human
patients in a manner that may or does reduce side-effects (such as,
e.g., nausea, vomiting or seizure).
[0019] It is a further object of the present invention to provide a
method of treating pain with a drug and dosing regimen that
provides a positive benefit-risk profile, and which addresses an
unmet medical need for the management of acute postoperative
pain.
[0020] In accordance with the above objects and others, the present
invention is directed in part to the co-administration of
intravenous tramadol and an intravenous nonsteroidal
anti-inflammatory drug (NSAID) to a human patient(s) to treat acute
pain. In certain embodiments, the co-administration occurs either
prior to, during, or after surgery.
[0021] In accordance with the above objects and others, the present
invention is directed in part to a method of administering tramadol
for treating pain via an intravenous dosing regimen comprising
intravenously administering a first dose of tramadol to a human
patient in an amount from about 45 mg to about 80 mg; and
concurrently administering an intravenous dose of an NSAID; and
thereafter intravenously administering the doses of tramadol and an
NSAID about every 5 to about every 7 hours, preferably about every
6 hours until the patient no longer requires treatment for pain,
e.g., with intravenous tramadol. The intravenous dosing regimen
preferably provides a Cmax of tramadol which is similar to the Cmax
of an oral dose of 100 mg tramadol HCl given every 6 hours at
steady-state. In certain preferred embodiments, each dose of
tramadol is about 60 mg. The intravenous dosing regimen preferably
provides a Cmax of tramadol which is similar to the Cmax of an oral
dose of 100 mg tramadol HCl given every 6 hours at steady-state. In
certain preferred embodiments, each dose of tramadol is about 60 mg
tramadol hydrochloride. In certain preferred embodiments, the NSAID
is ketorolac or a pharmaceutically acceptable salt or complex
thereof. In certain preferred embodiments, each dose of NSAID is
ketorolac tromethamine in an amount from about 10 to about 30
mg.
[0022] In certain preferred embodiments, the intravenous dosing
regimen of the invention provide a Cmax of tramadol at steady-state
that is from about 80% to about 125% of the Cmax provided at
steady-state by a 100 mg oral dose of tramadol HCl given every 6
hours, e.g., the intravenous dosing regimen provides a Cmax of
tramadol at steady-state from about 80% to about 125% of about 736
ng/mL. The method may further comprise continuing to administer
additional doses of tramadol and ketorolac to the human patient for
at least about 42 hours after the first administered dose of
tramadol.
[0023] In certain preferred embodiments, the method further
comprises diluting the dose of tramadol and NSAID (e.g., ketorolac)
in from about 50 ml to about 500 ml of a pharmaceutically
acceptable fluid for injection, and standardizing the
administration of the injection of the dose of tramadol and
ketorolac via the use of a pump. The dose may be provided in the
form of a sterile solution at a concentration of about 60 mg
tramadol hydrochloride and from about 10 mg to about 30mg NSAID
(e.g., ketorolac or its water soluble salt form, ketorolac
tromethamine) contained in one or more ampoules or vials. The
ampoules may contain the dose of tramadol together ketorolac with a
buffering agent in solution for injection, or the ampoules/vials
may separately contain the dose of tramadol in one ampoule and the
dose of ketorolac in another ampoule. In certain embodiments, the
method further comprises diluting the dose of tramadol and
ketorolac into an IV bag for administration to the human
patient.
[0024] The first dose of tramadol/NSAID may be administered to the
human patient intra-operatively at wound closure, or from first
demand of analgesia postoperatively, and administering further
doses of intravenous tramadol/ketorolac for at least two days
post-surgery. In certain embodiments, the human patient is
suffering from acute post-operative pain.
[0025] The method may further comprise switching the human patient
after at least three intravenous doses of tramadol/NSAID (e.g.,
ketorolac), to oral doses of the same amount of tramadol and NSAID
(e.g., ketorolac) previously administered intravenously, such that
the Cmax of tramadol at the time the human patient is switched to
oral doses is similar to the Cmax provided at steady-state by a
dosing regimen of 100 mg tramadol HCl administered orally every 6
hours.
[0026] The method may further comprise administering an opioid
analgesic which is not tramadol to the human patient to treat
breakthrough pain.
[0027] In certain preferred embodiments, the invention is directed
to a method of administering tramadol for treating pain via an
intravenous dosing regimen, comprising intravenously administering
a first dose of tramadol to a human patient in an amount of about
45 mg to about 80 mg (e.g., about 60 mg); and concurrently
administering a therapeutically effective intravenous dose of
ketorolac (e.g., ketorolac tromethamine in an amount of about 10 mg
to about 30 mg); and thereafter intravenously administering the
doses of tramadol and ketorolac about every 5 to about 7 hours
(e.g., preferably about every 6 hours) until the patient no longer
requires treatment with intravenous tramadol, wherein the tramadol
is tramadol base or a pharmaceutically acceptable salt of tramadol,
such that the intravenous dosing regimen provides a Cmax of
tramadol which is similar to the Cmax of an oral dose of 100 mg
tramadol HCl given every 6 hours at steady-state. The intravenous
dosing regimen of the invention preferably provides a Cmax of
tramadol at steady-state that is from about 80% to about 125% of
the Cmax provided at steady-state by a 100 mg oral dose of tramadol
HCl given every 6 hours, e.g., the intravenous dosing regimen
provides a Cmax of tramadol at steady-state from about 80% to about
125% of about 736 ng/mL.
[0028] In certain preferred embodiments, the intravenous dosing
regimens of the invention provide a Cmax of the M1 metabolite of
tramadol at steady-state that is from about 20% to about 125% (in
certain embodiments from about 60% to about 75%), or from about 80%
to about 125% of the Cmax of the M1 metabolite of tramadol at
steady-state when the tramadol is administered as oral 100 mg
tramadol HCl every 6 hours.
[0029] In certain embodiments of the intravenous dosing regimens of
the invention, the intravenous dosing regimen provides a Cmax of
tramadol at steady-state from about 80% to about 125% of about 736
ng/mL.
[0030] In preferred embodiments of the intravenous dosing regimens
of the invention, each dose of tramadol and NSAID (e.g., ketorolac)
is administered intravenously over a time period from about 10
minutes to about 20 minutes. In certain preferred embodiments, each
dose of the tramadol and ketorolac is administered over a time
interval of 15 (.+-.2) minutes.
[0031] In certain preferred embodiments of the intravenous dosing
regimens of the invention, the method further comprises
administering a first intravenous dose of tramadol and ketorolac to
the patient intra-operatively at wound closure, or from first
demand of analgesia post-operatively, and administering said
further doses of intravenous tramadol for at least two days
post-surgery.
[0032] In certain preferred embodiments of the intravenous dosing
regimens of the invention, the method further comprises
administering one or more doses of an intravenous opioid analgesic
as rescue medicine to the patient to treat breakthrough pain.
[0033] In certain preferred embodiments of the intravenous dosing
regimens of the invention, the method further comprises
administering the first dose of tramadol and ketorolac on first
demand of analgesia post-operatively, further comprising
administering a therapeutically effective dose intravenous opioid
analgesic to the patient at the end of the surgery.
[0034] In certain preferred embodiments of the intravenous dosing
regimens of the invention, the method further comprises
administering the first dose of tramadol and ketorolac to the
patient intra-operatively at wound closure, further comprising
administering a bolus of a therapeutically effective dose of
intravenous opioid analgesic to the patient if the patient requests
analgesia before the second dose of intravenous
tramadol/ketorolac.
[0035] In certain preferred embodiments of the intravenous dosing
regimens of the invention, the method further comprises
administering a rescue opioid analgesic using Patient Controlled
Analgesia (PCA).
[0036] In certain preferred embodiments of the intravenous dosing
regimens of the invention, the treatment of pain in the patient is
conventional opioid-sparing over the first, e.g., 24, 30, 36, 42 or
48 hours post-surgery.
[0037] In certain preferred embodiments of the intravenous dosing
regimens of the invention, the method further comprises diluting
tramadol in a volume of normal saline to provide a unit dose from
about 45 mg to about 80 mg tramadol and from about 10 mg to about
30 mg ketorolac in a volume of normal saline; administering the
dose intravenously over a time period, e.g., from about 15 (.+-.2)
minutes. In certain preferred embodiments of the intravenous dosing
regimens of the invention, the method further comprises diluting
tramadol in a volume of normal saline to provide a unit dose of
about 60 mg tramadol and from about 10 mg to about 30 mg ketorolac
in a volume of normal saline; administering the dose intravenously
over a time period (e.g., from about 15 (.+-.2) minutes).
[0038] In certain preferred embodiments of the intravenous dosing
regimens of the invention, the dose prior to dilution is contained
in one or more ampoules.
[0039] In certain preferred embodiments of the intravenous dosing
regimens of the invention, the ampoules contain tramadol
hydrochloride and ketorolac in water for injection, optionally with
additional pharmaceutically acceptable excipients (e.g., a
buffer).
[0040] In certain embodiments of the intravenous dosing regimens of
the invention, the human patient(s) is suffering from acute
post-operative pain.
[0041] In certain preferred embodiments of the intravenous dosing
regimens of the invention, the method provides a reduction in at
least one side-effect associated with tramadol therapy (e.g., as
compared to prior art intravenous dosing regimens), wherein the
side-effect is nausea, vomiting, or seizure.
[0042] In certain preferred embodiments of the intravenous dosing
regimens of the invention, the method further comprises
administering a therapeutically effective dose of an intravenous
opioid analgesic is administered to the patient (i) at the end of
the surgery, (ii) if the patient requests analgesia before the
second dose of tramadol, or (iii) both (i) and (ii).
[0043] In certain preferred embodiments, the present invention is
directed in part to a method of treating pain, comprising
administering to a human patient(s) a therapeutically effective
dose of tramadol and NSAID (e.g., ketorolac) intravenously over a
time period from about 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19,
20 21, 22, 23, 24, 25, 26, 27,28, 29 30, 31, 32, 33, 34, 35, 36,
37, 38, 39, 40, 41, 42, 43, 44 or 45 minutes.
[0044] Further aspects of the invention are directed to diluting
the dose of tramadol and ketorolac in from about 50 ml to about 500
ml (and preferably from about 50 ml to about 100 ml) of a
pharmaceutically acceptable fluid for injection such as normal
saline, e.g., in a bag or vial, and standardizing the
administration of the injection of the dose of tramadol and
ketorolac via the use of a pump. In another embodiment, the dose is
provided in the form of a sterile solution composed of about 45 mg
to about 80 mg mg (e.g., about 60 mg) tramadol hydrochloride and
from about 10 mg to about 30 mg ketorolac (e.g., ketorolac
tromethamine).
[0045] In certain further preferred embodiments, the dose of
tramadol prior to dilution is contained in one or more ampoules. In
certain preferred embodiments, the ampoules may contain the dose of
tramadol (e.g., tramadol hydrochloride) together with ketorolac,
alone or with a buffering agent (e.g., sodium acetate) in water for
injection (e.g., about 1 ml to about 5 ml).
[0046] In certain further preferred embodiments, the method further
comprises diluting the dose of tramadol and ketorolac into an IV
bag or ampoule/vial for administration to the patient.
[0047] In certain preferred embodiments of the present invention,
the method further comprises administering a first dose of
tramadol/ketorolac to the patient intra-operatively at wound
closure, or from first demand of analgesia postoperatively, and
administering said further doses of intravenous tramadol/ketorolac
for at least two days post-surgery.
[0048] In certain preferred embodiments of the present invention,
the method further comprises the concomitant administration of one
or more opioid analgesics, preferably via the injectable (e.g.,
intravenous) route as rescue medicine to the patient to treat
breakthrough pain that the patient experiences, e.g., for the time
period of at least about 48 hours post-surgery. Several options are
available for postoperative pain management (Singelyn et al., 1998;
Sinatra et al., 2002; both of which are hereby incorporated by
reference). Options include intermittent "on-demand" analgesia,
continuous epidural analgesia with opioids and/or local anesthetics
is effective, or to provide a combination of nerve blocks with
long-acting local anesthetics and/or opioids initiated
intra-operatively and continued into the immediate postoperative
period. For example, most Total knee Arthroplasty (TKA) or Total
Hip Arthroplasty (THA) procedures are currently performed with
regional (or neuraxial) or other nerve blocks and without general
anesthesia. In certain preferred embodiments of the invention, the
method further comprises administering a rescue opioid analgesic
using Patient Controlled Analgesia (PCA). In certain preferred
embodiments, the intravenous administration of opioid analgesic
also or alternatively comprises opioid analgesic (e.g., morphine)
intravenously to the patient at an effective dose (e.g., morphine
in an amount of about 0.05mg/kg) as a bolus at the end of surgery
or upon first demand of analgesia postoperatively, to provide
effective analgesia to the patient(s).
[0049] In certain preferred embodiments of the invention, the first
dose of tramadol is administered on first demand of analgesia
postoperatively. Thereafter, the method may further comprise
administering a (analgesically) therapeutically effective dose
intravenous opioid analgesic to the patient at the end of the
surgery, to provide effective analgesia to the patient(s).
[0050] In certain preferred embodiments of the invention, the first
dose of tramadol is administered to the patient intra-operatively
at wound closure. In such embodiments, the method may further
comprise administering a bolus of a (analgesically) therapeutically
effective dose of intravenous opioid analgesic to the patient if
the patient requests analgesia before the second dose of tramadol,
to provide effective analgesia to the patient(s).
[0051] In preferred embodiments where the tramadol is administered
for the treatment of post-operative pain, the treatment of pain in
the patient is opioid-sparing over the first 48 hours
post-surgery.
[0052] In other preferred embodiments, the human patient(s)
suffering from pain is unable to ingest an oral dosage form (e.g.,
of tramadol or another opioid analgesic and/or an NSAID) because
the patient is suffering from cancer pain.
[0053] In accordance with the above, the final drug product
(containing the intravenous dose of tramadol) may be presented as,
e.g., as unit-dose ampoules, unit-dose vials, multi-dose ampoules,
multi-dose vials, and drug in pre-mixed bags.
[0054] In certain preferred embodiments, the M1 metabolite of
tramadol (O-desmethyltramadol) contributes to analgesic effect
provided by the present invention (dosing regimen), without being
toxic (e.g., without significant side effects) to humans at the
administered dose of intravenous tramadol.
[0055] In certain embodiments, the method may provide a faster
onset of pain relief than oral doses of 100 mg tramadol HCl given
every 6 hours.
[0056] The invention is further directed in part to the above
methods, wherein the safety and tolerability of tramadol for
treating pain in human patients is improved.
[0057] In certain preferred embodiments, the pharmacokinetic
profile (e.g., Cmax) achieved by this 45 - 80 mg, preferably about
60 mg IV tramadol dosing regimen at a time where the patient might
be switched to oral meds (e.g., after the 44-48 hour dosing
interval) is similar to the pharmacokinetic profile (e.g., Cmax)
provided at steady-state by a dosing regimen of 100 mg tramadol HCl
administered orally every 6 hours. This allows the patient to be
stepped down from the intravenous tramadol dosing regimen to an
oral dosing regimen. In turn, this allows the patient to be
discharged from hospital care with less concern about deleterious
effects which might occur from a switch from intravenous to oral
analgesic medicine (e.g., the switch to an oral version of the drug
providing a much different Cmax).
[0058] The term "about 60 mg" with respect to the tramadol dose
should be construed with the goal of the present invention in
mind--the dose of the dose ("about") may be adjusted to a limited
degree, e.g., as long as the goal of a mean Cmax which is similar
to the mean steady-state Cmax that is obtained via the
administration of an oral dosing regimen of 100 mg tramadol
administered to human patients every 6 hours (if the dosing regimen
is continued for 48 hours). Generally speaking, it should be
recognized that the dose(s) of intravenous tramadol may be
modified, e.g., to a dose from about 45 mg to about 80 mg and
intravenous NSAID (e.g., ketorolac) may be modified to a dose from
about 10 mg to about 30 mg, and a dosing interval for the second
dose and onward of intravenous tramadol/NSAID (e.g., ketorolac) may
be modified, e.g., as long as the goal of a mean Cmax of tramadol
is obtained which is similar to the mean steady-state Cmax is
obtained via the administration of an oral dosing regimen of 100 mg
tramadol administered to human patients every 6 hours (if the
dosing regimen is continued for 48 hours) in order to provide
treatment of pain (e.g., acute pain) in the human patient(s).
Within those parameters, the dose of ketorolac may be modified in
order to provide adequate or improved pain relief than that
obtained with the tramadol dosing alone.
[0059] In additional embodiments, the invention is directed to a
method of reducing surgical pain in human patients, comprising
administering the intravenous dosing regimen of tramadol and
acetaminophen as described herein, such that the patient
experiences relief from pain associated with the surgery. In
preferred embodiments, the method further comprises intravenously
co-administering a 60 mg dose of intravenous tramadol and a
therapeutically effective dose of ketorolac about every six hours
post-operatively to the patient. Preferably, the intravenous
tramadol/ketorolac therapy is continued until the patient no longer
is suffering from post-operative pain.
[0060] Additional embodiments of the present invention are directed
to a kit, comprising a vial containing an intravenous dose of
tramadol or a pharmaceutically acceptable salt thereof in an amount
from about 45 mg to about 80 mg (based on the hydrochloride salt);
and a vial containing an intravenous dose of acetaminophen in an
amount from about 500 mg to about 1,000 mg. In certain embodiments,
the kit contains additional doses of tramadol and acetaminophen. In
certain preferred embodiments, the kit contains sufficient doses of
tramadol and acetaminophen to be administered about every 5 to
about every 7 hours (e.g., about every 6 hours) until the patient
no longer requires treatment with intravenous tramadol, e.g., up to
about 48 hours after initiation of dosing (e.g., about 8 doses of
each drug). In certain embodiments, the doses of tramadol HCl and
acetaminophen are contained within the same vial, and the kit
contains separate vials for each dosing interval, e.g., until the
patient no longer requires treatment with intravenous tramadol,
e.g., up to about 48 hours after initiation of dosing (e.g., about
8 doses). In other embodiments, the doses of tramadol HCl and
acetaminophen are contained within separate vials, and the kit
contains vials for each dosing interval, e.g., until the patient no
longer requires treatment with intravenous tramadol, e.g., up to
about 48 hours after initiation of dosing (e.g., about 8 doses).
The intravenous dosing regimen contained in the kit preferably
provides a Cmax of tramadol which is similar to the Cmax of an oral
dose of 100 mg tramadol HCl given every 6 hours at steady-state. In
certain preferred embodiments, each dose of tramadol is about 60
mg. In certain preferred embodiments, each dose of ketorolac is
from about 10 mg to about 30 mg.
[0061] The methods of the present invention are described in
further detail in the following sections. However, it should be
understood that for purposes of the present invention, the
following terms have the following meanings:
[0062] The term "acute pain" as used herein means pain that has a
sudden onset and commonly declines over a short time (days, hours,
minutes) and follows injury to the body and which generally
disappears when the bodily injury heals.
[0063] The term "effective analgesia" is defined for purposes of
the present invention as a satisfactory reduction in or elimination
of pain, along with the process of a tolerable level of side
effects, as determined by the human patient.
[0064] The term "effective pain management" means for purposes of
the present invention as the objective evaluation of a human
patient's response (pain expressed versus side effects) to
analgesic treatment by a physician as well as subjective evaluation
of therapeutic treatment by the patient undergoing such treatment.
The skilled artisan will understand that effective analgesia will
vary according to many factors, including individual patient
variations.
[0065] The term "breakthrough pain" means pain which the patient
experiences despite the fact that the patient is being administered
generally effective amounts of, e.g., an opioid analgesic such as
buprenorphine.
[0066] The term "rescue" refers to a dose of an analgesic which is
administered to a patient experiencing breakthrough pain.
[0067] An "effective amount" is an amount sufficient to effect
beneficial or desired clinical results including alleviation or
reduction in pain. In some embodiments, the "effective amount" may
reduce the pain of ongoing pain and/or breakthrough pain (including
ambulatory pain and touch-evoked pain).
[0068] The term "parenterally" as used herein includes subcutaneous
injections, intravenous, intramuscular, intrasternal injection or
infusion techniques.
[0069] The term "patient" as used herein refers to a warm blooded
animal such as a mammal which is the subject of trauma, e.g.,
surgical trauma. It is understood that at least humans, dogs, cats,
and mice are within the scope of the meaning of the term.
[0070] As used herein, the term "treat" or "treatment", or a
derivative thereof, contemplates partial or complete inhibition of
acute pain, when a composition of the present invention is
administered following the onset of acute pain.
[0071] All numbers expressing quantities of ingredients, reaction
conditions, and so forth used in the specification and claims are
to be understood as being modified in all instances by the term
"about." Accordingly, unless indicated to the contrary, the
numerical parameters set forth in the specification and attached
claims are approximations that may vary depending upon the desired
properties sought to be obtained by the present invention. At the
very least, and not as an attempt to limit the application of the
doctrine of equivalents to the scope of the claims, each numerical
parameter should be construed in light of the number of significant
digits and ordinary rounding approaches.
[0072] As used herein a "dosage regimen" refers to the protocol
used to administer an intravenous pharmaceutical formulation
comprising ibuprofen to a patient. In some embodiments the dosage
regimen comprises a dose amount and dosing interval.
[0073] As used herein, the term "tramadol" encompasses tramadol
base, salt and complex forms, unless otherwise specified. The doses
of tramadol are based on tramadol hydrochloride.
[0074] As used herein, the term "ketorolac" encompasses ketorolac
base, salt and complex forms, unless otherwise specified. The doses
of tramadol are based on ketorolac tromethamine.
DETAILED DESCRIPTION
[0075] The chemical name for tramadol is
(.+-.)cis-2-[(dimethylamino)methyl]-1-(3-methoxyphenyl)
cyclohexanol hydrochloride [or (1R,2R)-rel
-2-[(dimethyl-amino)methyl]-1-(3-methoxyphenyl) cyclohexanol
hydrochloride, (1RS,
2RS)-2-[(dimethylamino)methyl]-1-(3-methoxyphenyl) cyclohexanol
hydrochloride, (.+-.)-(RR,
SS)-2-[(dimethylamino)methyl]-1-(3-methoxyphenyl) cyclohexanol
hydrochloride]. Unless otherwise specified, the term tramadol
refers to the racemic mixture of the (.+-.)cis isomers.
[0076] Tramadol is a centrally-acting synthetic analgesic of the
aminocyclohexanol group with opioid-like effects. Tramadol is
extensively metabolized following administration resulting in a
number of enantiomeric metabolites which display different
opioid-receptor binding properties, and monoaminergic reuptake
inhibition (Grond and Sablotzki, 2004). Both enantiomers of
tramadol and (+)-M1 are responsible for the analgesic effect. The
primary metabolite [(+)-M1 or (+)-O-desmethyltramadol] of tramadol
confers significant .mu.-opioid activity; (+)-tramadol confers weak
.mu.-opioid activity and significant serotonin reuptake inhibition;
and (-)-tramadol is responsible for the inhibition of noradrenaline
re-uptake (Gillen et al., 2000; Raffa, 2008). Nonclinical studies
have shown that antinociception induced by tramadol is only
partially antagonized by the opiate antagonist, naloxone,
indicating that non-opioid mechanisms are also involved in its
pharmacodynamic action (Collart et al., 1992).
[0077] Tramadol has efficacy in management of acute postoperative
pain equivalent to morphine and other opioids administered
intravenously, although the onset of action for tramadol is slower.
The parenteral route has the advantage of immediate bioavailability
and faster onset of action than oral, and is available to
postoperative patients who cannot take oral medications. Current
standard-of-care injectable analgesics (opioids and NSAIDs) have
significant adverse effects, including opiate-induced respiratory
depression, excessive sedation, hypotension, dependency, increased
bleeding risk, renal toxicity and gastrointestinal irritation,
which can potentially slow the postoperative rehabilitation process
and compound the risk inherent in any surgical procedure.
[0078] Tramadol is currently commercially available in various
countries/territories in the following forms: 50 mg/ ml or 100 mg/
2 ml, solution for injection; 50 mg, capsules, hard; 50 mg,
prolonged-release tablets; 100 mg, prolonged-release tablets; 150
mg, prolonged-release tablets; 200 mg, prolonged-release tablets;
50 mg, tablets; 100 mg/ ml, oral drops, solution; and 100 mg,
suppositories. In the U.S., tramadol is approved by the Food and
Drug Administration (FDA) and marketed as an oral capsule/tablet
for moderate to moderately severe pain in adults, e.g., under the
tradename Ultram.RTM. (tramadol hydrochloride tablets).
[0079] Parenteral tramadol has been used extensively in Europe and
other areas of the world for the amelioration of postoperative pain
in both adults and children. The efficacy of tramadol has been
thoroughly reviewed (Lee CR, McTavish D, Sorkin EM. Tramadol. A
preliminary review of its pharmacodynamic and pharmacokinetic
properties, and therapeutic potential in acute and chronic pain
states. Drugs. 1993;46:313-340; Scott L J, Perry C M. Tramadol. A
review of its use in perioperative pain. Drugs. 2000;60:139-176;
Grond S and Slabotzi A. Clinical pharmacology of tramadol. Clin
Pharmacokinet. 2004;43:879-923). Parenteral tramadol in such
territories consists of tramadol 50 mg or 100 mg administered as a
slow bolus injection (over 2-3 minutes) every 4-6 hours.
[0080] In the present invention, a therapeutically effective dose
of tramadol is administered parenterally (e.g., intravenously)
along with a parenteral (e.g., intravenous) administration of an
NSAID. The NSAID may be administered in via the same route of
administration (e.g., iv) or may be administered separately. By
"along with", it is meant that the dose of tramadol and NSAID are
administered at about the same time so that these two drugs may
continue to be administered at about the same dosage intervals. For
example, it is contemplated in certain preferred embodiments that
tramadol will be administered in a therapeutically effective amount
intravenously (e.g., from about 45 mg to about 80 mg in each dose)
and that a therapeutically effective amount of NSAID is
intravenously administered at the same time. It is further
contemplated that each dose of tramadol will be administered at a
dosing interval from about every 4 hours to about every 7 hours,
and in certain preferred embodiments about every 6 hours.
Preferably, the intravenous NSAID can be administered at the same
dosing interval as the tramadol.
[0081] Examples of nonsteroidal anti-inflammatory drugs (NSAIDs)
that can be administered in the methods of the present invention
include nabumetone, celecoxib, etodolac, nimesulide, apasone, gold,
oxicams, such as piroxicam, isoxicam, meloxicam, tenoxicam,
sudoxicam, and CP-14,304; a salicylate, such as aspirin, disalcid,
benorylate, trilisate, safapryn, solprin, diflunisal, and fendosal;
an acetic acid derivatives, such as diclofenac, fenclofenac,
indomethacin, sulindac, tolmetin, isoxepac, furofenac, tiopinac,
zidometacin, acematacin, fentiazac, zomepirac, clindanac, oxepinac,
felbinac, and ketorolac; fenamates, such as mefenamic,
meclofenamic, flufenamic, niflumic, and tolfenamic acids; propionic
acid derivatives, such as ibuprofen, naproxen, benoxaprofen,
flurbiprofen, ketoprofen, fenoprofen, fenbufen, ketorolac,
sulfasalazine, indopropfen, pirprofen, carprofen, oxaprozin,
pranoprofen, miroprofen, tioxaprofen, suprofen, alminoprofen, and
tiaprofenic; or pyrazoles, such as phenylbutazone, oxyphenbutazone,
feprazone, azapropazone, and trimethazone. Ketorolac is especially
preferred.
[0082] Ketorolac is an NSAID in the family of heterocyclic acetic
acid derivatives, and is used as an analgesic, particularly for the
treatment of short-term moderate to severe pain. Ketorolac acts by
inhibiting the bodily synthesis of prostaglandins. Ketorolac in its
oral (tablet or capsule) and intramuscular (injected) preparations
is a racemic mixture of both (S)-(-)-ketorolac, the active isomer,
and (R)-(+)-ketorolac.
[0083] Ketorolac is approved in the U.S. and is a member of the
pyrrolo-pyrrole group of NSAIDs. It is commercially available from
multiple companies as an injection (15 mg/ml or 30 mg/ml ketorolac
tromethamine, or as a prefilled syringe as 15 mg/ml, 30 mg/ml and
60 mg/2 ml). It is available as tablet for oral administration (10
mg ketorolac tromethamine). It is also available as an irrigation
solution (EQ 0.3% base; EQ 1% base), a nasal spray and an
ophthalmic solution. Ketorolac tromethamine was originally
commercially available in the U.S. under the brand name
Toradol.RTM. from Roche Palo Alto LLC (discontinued for reasons
other than safety or efficacy). It is typically administered in a
dose from about 10 to about 30 mg (e.g., 10 mg, 15 mg or 30 mg)
once about every 6 hours, with doses preferably not exceeded 60-120
mg/day.
[0084] The chemical name for ketorolac tromethamine is
(.+-.)-5-benzoyl-2,3-dihydro-1H-pyrrolizine-1-carboxylic acid,
compound with 2-amino-2-(hydroxymethyl)-1,3-propanediol (1:1), and
the chemical structure is:
##STR00001##
[0085] Ketorolac tromethamine is a racemic mixture of [-]S and [+]R
ketorolac tromethamine. Ketorolac tromethamine may exist in three
crystal forms. All forms are equally soluble in water. The
structure of ketorolac tromethamine is as follows:
##STR00002##
[0086] Ketorolac tromethamine may be administered as an IV push.
Bolus intravenous doses should generally be given over at least 15
seconds. The time to onset of analgesia following IV or IM
administration is approximately 30 minutes for a therapeutically
effective dose (e.g., from about 10 mg to about 30 mg), and maximum
analgesia occurs within about 1-2 hours.
[0087] In certain embodiments, ketorolac (e.g., in the form of
ketorolac tromethamine) may be administered in a dose of about 10
mg, 11 mg, 12 mg, 13 mg, 14 mg, 15 mg, 16 mg, 17 mg, 18 mg, 19 mg,
20 mg, 21 mg, 22 mg, 23 mg, 24 mg, 25 mg, 26 mg, 27 mg, 28 mg, 29
mg, 30 mg, 31 mg, 32 mg, 33 mg , 34 mg, 35 mg, 36 mg, 37 mg, 38 mg,
39 mg, 40 mg, 41 mg, 42 mg, 43 mg, 44 mg, 45 mg, 46 mg, 47 mg, 48
mg, 49 mg, 50 mg, 51 mg, 52 mg, 53 mg, 54 mg, 55 mg, 56 mg, 57 mg,
58 mg, 59 mg, and about 60 mg.
[0088] The pharmacokinetics of ketorolac tromethamine in adults,
following single or multiple IM, IV or oral doses of ketorolac
tromethamine or recommended oral doses of TORADOL, are considered
to be linear. The half-life of the ketorolac tromethamine
S-enantiomer has previously been reported to be about 2.5 hours
compared with about 5 hours for the R-enantiomer. In other
previously reported studies, the half-life for the racemate has
been reported to lie within the range of 5 to 6 hours. The package
insert for Toradol states that ketorolac tromethamine administered
as an IV bolus every 6 hours for 5 days to healthy subjects (n=13),
showed no significant difference in Cmax on Day 1 and Day 5. Trough
levels averaged about 0.29 .mu.g/mL (on Day 1 and about 0.55
.mu.g/mL on Day 6. Steady state was approached after the fourth
dose.
[0089] In certain preferred embodiments, the intravenous tramadol
and ketorolac doses are administered intravenously at the same time
post-surgery, at dosing intervals of every 5 to about every 7
hours.
[0090] In certain embodiments, the parenteral treatments of
tramadol/ketorolac described herein are supplemented with a further
concomitant dose of acetaminophen. Acetaminophen is a
non-salicylate antipyretic and non-opioid analgesic agent. Its
chemical name is N-acetyl-p-aminophenol. Acetaminophen injection is
indicated for the management of mild to moderate pain; the
management of moderate to severe pain with adjunctive opioid
analgesics; and the reduction of fever. Acetaminophen injection is
available in the U.S. under the tradename Ofirmev.TM. from Cadence
Pharmaceuticals, Inc. It is supplied in a 100 mL glass vial
containing 1000 mg acetaminophen (10 mg/mL) and the vials are
approved for single use only. Acetaminophen injection can be
administered, e.g., as a 15 minute infusion or as a 30 minute
infusion, and may be administered every 4 to 6 hours. The maximum
recommended dose of acetaminophen on a daily basis to adults is
4000 mg. Ofirmev injection is a sterile, clear, colorless, non
-pyrogenic, isotonic formulation of acetaminophen for intravenous
infusion. It is a pH of about 5.5 and an osmolality of about 290
mOsm/kg. Each 100 mL contains 1000 mg acetaminophen, USP, 3840 mg
mannitol, USP, 25 mg cysteine hydrochloride, monohydrate, USP, 10.4
mg dibasic sodium phosphate, anhydrous, USP. The pH is adjusted
with hydrochloric acid and/or sodium chloride. The dosage of
Ofirmev for adults and adolescents weighing 50 kg and over is 1000
mg every 6 hours or 650 mg every 4 hours, with a maximum single
dose of Ofirmev of 1000 mg and a minimum dosing interval of 4 hours
and a maximum daily dose of acetaminophen of 4000 mg per day. For
adults, adolescents weighing under 50 kg, and children from 2 to 12
years of age, the recommended dosage of Ofirmev is 15 mg/kg every 6
hours or 12.5 mg/kg every 4 hours, with a maximum single dose of
Ofirmev of 15 mg/kg, and a maximum daily dose of acetaminophen of
75 mg/kg per day. In embodiments of the present invention in which
a dose of intravenous acetaminophen is added to the dose of
tramadol/NSAID (e.g., ketorolac), the dose of acetaminophen
administered may be from about 100 mg to about 1000 mg. The dose of
acetaminophen may be administered at the same time(s) as the dose
of intravenous tramadol/NSAID.
[0091] In certain preferred embodiments, the tramadol and ketorolac
doses are contained within a single unit dose, e.g., inside a vial.
In other preferred embodiments, the tramadol and ketorolac doses
are separately contained within ampoules or vials and may be
combined (or not combined) when administered concomitantly via
injection. Due to the fact that tramadol is generally administered
over a longer period of time (e.g., from about 2-20 minutes,
preferably between 10-20 minutes IV) and ketorolac may be
administered an IV push, in some embodiments of the invention it is
contemplated that the dosages are administered separately although
concomitantly. In other preferred embodiments, the tramadol and
ketorolac doses may both be administered as an IV push, together or
separately.
[0092] The invention is further directed to a method of treating at
post-surgical patient in need of pain relief comprising
administering to the patient an intravenous pharmaceutical
composition comprising intravenous tramadol together with
intravenous acetaminophen. In certain preferred embodiments of this
method, the dose of acetaminophen produces a decreased need for
tramadol and/or a additional opioid analgesic, decreased side
effects from use of a narcotic analgesic and/or decreased
perception of pain.
[0093] The co-administration of intravenous tramadol and NSAID used
in accordance with the invention provides a treatment for pain
and/or fever using the intravenous route of administration, and is
useful, e.g., for the treatment of mild to severe pain (and
particularly acute pain) in adults and children over 12 years of
age. Co-administration of intravenous tramadol and NSAID (e.g.,
ketorolac) used in accordance with the methods of the invention
provides pain control, e.g., for abdominal and orthopedic surgical
procedures; may be opioid sparing when used for post-operative
pain; may provide a reduction in opioid side effects; provides a
reduction in adverse events, may provide a reduction in the need
for anti-emetic medications, may allow patients to become
ambulatory faster.
[0094] The co-administration of intravenous tramadol and NSAID in
accordance with the present invention may provide the following
benefits, for example: speeds relief of pain to expedite release
from a hospital or hospital-like setting; speeds relief to expedite
hospital release, as demonstrated by a fast reduction of mild to
severe pain in adults and children over 12 years of age; a
reduction in pain at rest and with movement as measured by visual
analog scores (VAS) following abdominal and orthopedic surgeries; a
reduction in opioid side effects (nausea, vomiting, constipation);
preferably does not cause bleeding or renal concerns; and may
provide an improvement in time to ambulation which may enable
facilities to schedule additional procedures in the ambulatory
setting.
[0095] Surgical procedures often result in some form of acute pain.
Surgical pain may include nociceptive, neuropathic or psychological
components. Nociceptive pain is a pain experienced as a result of
nociception, which is detection of a stimulus by a pain receptor
(nociceptor) and transmission of the information to the brain along
nerves. Nociceptive pain is caused by tissue damage and
inflammation in response to trauma. The resulting pain is usually
not well localized and is opioid responsive.
[0096] Several options are available for postoperative pain
management (Singelyn et al., 1998; Sinatra et al., 2002). Options
include intermittent "on-demand" analgesia, continuous epidural
analgesia with opioids and/or local anesthetics is effective, or to
provide a combination of nerve blocks with long-acting local
anesthetics and/or opioids initiated intra-operatively and
continued into the immediate postoperative period. In the United
States (US) and in India, this latter strategy is frequently
employed, and most TKA and THA procedures are currently performed
with regional (or neuraxial) or other nerve blocks and without
general anesthesia. Each of these options for postoperative pain
management can be used concomitantly with the intravenous tramadol
treatments described herein as recue medicine to treat breakthrough
pain.
[0097] The present invention is directed in part to tramadol and
NSAID in a pharmaceutically acceptable sterile solution
formulation(s) containing an effective dose of tramadol or a
pharmaceutically acceptable salt thereof, either in combination
with an effective dose of NSAID (e.g., ketorolac) together or in
separate intravenous formulations and a method of administration of
the same for the treatment of pain, e.g., postoperatively. Tramadol
injection and NSAID injection in accordance with the present
invention will fulfill an important need by providing a safe and
effective alternative injectable analgesic for use in the acute
postoperative setting.
[0098] Preferably, the dose of tramadol administered in accordance
with the present invention is, e.g., from about 45 mg to about 80
mg, and in certain preferred embodiments from about 45 to about 55
mg, or from about 70 to about 80 mg, or from about 55 to about 65
mg. In certain preferred embodiments, each tramadol dose
administered is in the amount of, e.g., 45, 46, 47, 48, 49, 50, 51,
52, 53, 54, 55, 56, 57, 58, 59,60, 61, 62, 63, 64, 65, 66, 67, 68,
69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79 or 80 mg, e.g., provided
as tramadol hydrochloride. The tramadol may be provided, e.g., as
60 mg tramadol hydrochloride/1 ml. The injectable tramadol dose is
generally intended for in-hospital use, although it can be used in
other settings. In certain preferred embodiments, the tramadol
and/or NSAID is administered intravenously over a time period from
about 10 minutes to about 3 hours. In certain preferred
embodiments, the therapeutically effective dose of tramadol/NSAID
(e.g., ketorolac) is administered intravenously over a time period
from about 10 minutes to about 20 minutes, and in certain
embodiments about 15 (.+-.2) minutes. Thus, in preferred
embodiments, the therapeutically effective dose of tramadol
intravenously over a time period from about 9, 10, 11, 12, 13, 14,
15, 16, 17, 18, 19, or 20 minutes. However, as previously
explained, it is possible to administer certain NSAIDs faster than
tramadol via the IV route, and therefore these drugs may be
administered separately (although concomitantly) in accordance with
administration techniques well known to those skilled in the
art.
[0099] The dose of acetaminophen is preferably administered
intravenously simultaneously with the dose of tramadol. The dose of
acetaminophen may be from about 500 to about 1000 mg, preferably
from about 650 g to about 750 mg. In certain preferred embodiments,
the dose of ketorolac is 10, 11, 12, 13, 14, 15, 16, 17, 18, 19,
20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36,
37, 38, 39, or 40 mg (or higher).
[0100] Further aspects of the invention are directed to diluting
the dose of tramadol and NSAID (e.g., ketorolac) in from about 50
ml to about 100 ml of a pharmaceutically acceptable fluid for
injection (such as normal saline), and standardizing the
administration of the injection of the dose of tramadol via the use
of a pump. In preferred embodiments, the pump is an infusion pump
that is commercially available, such as pumps available from Braun
and Hospira.
[0101] As previously mentioned, the dose of tramadol administered
in accordance with the present invention may be diluted in a
suitable pharmaceutically acceptable carrier for injection.
Examples of such include sterile water for injection, normal
saline, etc. Intravenous fluids are well known to those of ordinary
skill in the art, and may include other ingredients beyond the dose
of tramadol and the carrier/solvent for the tramadol, e.g., sterile
solutions of simple chemicals such as sugars, amino acids or
electrolytes, which can be easily carried by the circulatory system
and assimilated. Such fluids are typically prepared with water for
injection USP. Fluids used commonly for intravenous (IV) use are
disclosed in Remington, The Science and Practice of Pharmacy [full
citation previously provided], and include: alcohol, e.g., 5%
alcohol (e.g., in dextrose and water ("D/W") or D/W in normal
saline solution ("NSS"), including in 5% dextrose and water
("D5/W"), or D5/W in NSS); synthetic amino acid such as Aminosyn,
FreAmine, Travasol, e.g., 3.5 or 7; 8.5; 3.5, 5.5 or 8.5%
respectively; ammonium chloride e.g., 2.14%; dextran 40, in NSS
e.g., 10% or in D5/W e.g., 10%; dextran 70, in NSS e.g., 6% or in
D5/W e.g., 6%; dextrose (glucose, D5/W) e.g., 2.5-50%; dextrose and
sodium chloride e.g., 5-20% dextrose and 0.22-0.9% NaCl; lactated
Ringer's (Hartmann's) e.g., NaCl 0.6%, KC1 0.03%, CaCl.sub.2 0.02%;
lactate 0.3%; mannitol e.g., 5%, optionally in combination with
dextrose e.g., 10% or NaCl e.g., 15 or 20%; multiple electrolyte
solutions with varying combinations of electrolytes, dextrose,
fructose, invert sugar Ringer's e.g., NaCl 0.86%, KC1 0.03%,
CaCl.sub.2 0.033%; sodium bicarbonate e.g., 5%; sodium chloride
e.g., 0.45, 0.9, 3, or 5%; sodium lactate e.g., 1/6 M; and sterile
water for injection The pH of such IV fluids may vary, and will
typically be from about 3.5 to about 8 as known in the art.
[0102] The dose of tramadol or pharmaceutically acceptable salts
thereof and acetaminophen can be administered alone or in
combination with other medical treatments, or other therapeutic
agents. When so-used, other therapeutic agents can be administered
before, concurrently (whether in separate dosage forms or in a
combined dosage form), or after administration of an active agent
of the present invention.
[0103] Consistent with the known clinical effects of opioids,
nonclinical safety pharmacology studies have shown that tramadol at
high doses affects the central nervous system (CNS), producing
sedation, impaired mobility, vomiting (dogs), decreased activity,
and convulsions (Matthiesen et al., 1998). Also consistent with
clinical effects, changes in blood pressure have been observed in
cardiovascular studies in rats at high doses (Raimundo et al.,
2006). Tramadol use, particularly with high doses, has been
associated with seizures, and the risk of seizures is increased in
the presence of drugs that reduce seizure threshold, head trauma or
prior history of seizures.
[0104] The toxicity of tramadol has been summarized by Matthiesen,
et al. (1998). The single-dose toxicity of tramadol was similar in
all species tested, independent of the route of administration.
Notable acute findings included restlessness, unsteady gait,
reduced spontaneous activity, exophthalmus, mydriasis, salivation,
vomiting (dog), tremor, convulsions, slight cyanosis and dyspnea.
The principle findings in repeat-dose toxicity studies in rats and
dogs were behavioral/clinical signs and convulsions at doses of
>25 mg/kg/day. The kidney and liver were identified as potential
target organs in rats, with mild effects (minimal tubular
vacuolization and perivenular hydropic degeneration, respectively)
following repeat intraperitoneal dosing at high doses of
tramadol.
[0105] There was no evidence of genotoxic potential for tramadol in
standard in vitro and in vivo studies (Matthiesen et al., 1998).
Carcinogenicity bioassays in mice and rats showed no evidence of
carcinogenic potential. An extensive reproductive and teratology
program revealed no safety concerns with respect to fertility or
teratogenic effects after oral administration (Matthiesen et al.,
1998; Yamamoto et al., 1972). Toxicity to offspring only occurred
at doses associated with maternal toxicity.
[0106] Following oral administration, tramadol is rapidly and
almost completely absorbed. The pharmacokinetics of tramadol were
evaluated in healthy male volunteers (n=10) in a crossover design
using 100 mg PO or IV doses (Lintz et al., 1986). Peak serum
concentrations (tmax) were reached approximately 2 hours after oral
dosing and the peak serum concentration (Cmax) for PO tramadol was
280.+-.49 ng/mL. The terminal half-life was 5.1 hours for PO and
5.2 hours for IV administration. The area under the serum tramadol
concentration-time curve (AUC) was 2488.+-.774 ngh/mL for PO and
3709.+-.977 ngh/mL for IV administration. Total clearance was
467.+-.124 mL/min for PO and 710.+-.174 mL/min for IV
administration. The absolute bioavailability of the oral dose was
68.+-.13%, based on comparison of the AUC values, while the
estimated absorption of the oral dose was 86-88%. The difference
between absorption and bioavailability was attributed to first pass
metabolism, which was estimated to be .about.20%. However, the
absolute bioavailability approaches 90-100% with continuous dosing,
probably due to saturation of first pass metabolism (Liao et al.,
1992). Other studies have corroborated these findings (Grond and
Sablotzki, 2004).
[0107] The pharmacokinetic profile of tramadol following i.v. and
p.o. administration in humans (n=10, male) is summarized in Table A
below (Lintz W, Barth H, Osterloh O, Schmidt-Bothelt E.
Bioavailability of enteral tramadol formulations. 1st
communication: capsules. Arzneim Forsch Drug Res.
1986;36:1278-1283). The absolute oral bioavailability of tramadol
was 68% (.+-.13) in humans.
TABLE-US-00001 TABLE A Pharmacokinetics of Tramadol (100 mg)
Following Intravenous and Oral Administration to Humans Tramadol
C.sub.max AUC.sub.0-24 h CL/F (100 mg) (ng/mL) t.sub.1/.sub.2 (h)
(ng h/mL) V.sub.d (L) (mL/min) i.v. -- 5.2 .+-. 0.8 3709 .+-. 977
203 .+-. 40 467 .+-. 124 p.o 280 .+-. 49 5.1 .+-. 0.8 2488 .+-. 774
306 .+-. 52 710 .+-. 174 Abbreviations: C.sub.max, maximal
concentration; t.sub.1/2, half-life; AUC, area under the plasma
concentration-time curve; CL, clearance; F, bioavailability;
V.sub.d; volume of distribution
[0108] The pharmacokinetic profile of tramadol and the (+)-M1 and
(-)-M1 metabolites was also evaluated in humans (N=12, male)
following p.o. administration of a single 1.5 mg/kg dose of
tramadol (Matthiesen, et al., 1993). The data are summarized in
Table B below:
TABLE-US-00002 TABLE B Pharmacokinetics of Tramadol and the (+) and
(-) Enantiomers of the M1 Metabolite Tramadol (1.5 mg/kg, C.sub.max
AUC CL/F [100 mg]) (ng/mL) T.sub.max (h) t.sub.1/.sub.2 (h) (ng
h/mL) (mL/min/kg) Tramadol 274 .+-. 75 1.6 .+-. 0.5 5.9 .+-. 0.7
2177 .+-. 722 742 .+-. 234 (+)-M1 147 .+-. 39 1.6 .+-. 0.5 6.0 .+-.
1.0 1258 .+-. 410 642 .+-. 204 (-)-M1 125 .+-. 32 1.5 .+-. 0.5 5.2
.+-. 0.8 908 .+-. 298 883 .+-. 264 Abbreviations: C.sub.max,
maximal concentration; T.sub.max, time to maximal concentration;
AUC, area under the plasma concentration-time curve; CL, clearance;
F, bioavailability; t.sub.1/2, half-life; V.sub.d; volume of
distribution
[0109] Tramadol undergoes hepatic metabolism and both the parent
drug and the active metabolite are excreted by the kidneys. The
active metabolite, M1 (O desmethyltramadol), is produced by the
action of CYP2D6 isozyme of the cytochrome P450 enzyme system. It
has a half-life of approximately 6.7 hours after oral
administration (single dose of 100 mg), compared to a half-life of
5.6 hours for tramadol administered intravenously. Hepatic
impairment results in decreased metabolism of both the parent
compound and the active metabolite. Tramadol is rapidly distributed
after IV administration with a distribution half-life in the
initial phase of 0.31.+-.0.17 hours, followed by a slower
distribution phase with a half-life of 1.7.+-.0.4 hours (Lintz et
al., 1986). The volumes of distribution following PO and IV
administration were 306 L and 203 L, respectively, indicating that
tramadol has a high tissue affinity. The protein binding of
tramadol is approximately 20%; however, saturation of binding sites
does not occur in the therapeutic dose range (Ultram.RTM.
Prescribing Information, 2009).
[0110] Elimination half-life increases approximately 2-fold in
subjects with renal or hepatic impairment. Patients who metabolize
drugs poorly via CYP2D6 (Caucasian population prevalence .about.8%)
may obtain reduced benefit from tramadol due to reduced formation
of M1 (Ultram.RTM. Prescribing Information, Ortho-McNeil-Janssen
Pharmaceuticals, Inc, 2009).
[0111] Studies of IV tramadol in the postoperative setting have
shown an acceptable safety profile. Loading doses up to 150 mg IV
were not associated with any serious adverse effects (Silvasti et
al., 2000). Also, no serious adverse effects were observed in
clinical trials of tramadol with mean (.+-.SD) cumulative doses of
449.+-.66 mg (Rud et al., 1994), 677.+-.473 mg (range 128-1750 mg)
(Silvasti et al., 2000), and 868.3.+-.412.2 mg (Pang et al., 1999)
over 24, 36 and 48 h respectively.
[0112] The most common adverse events, nausea, dizziness, headache,
somnolence, sweating, fatigue, constipation, dry mouth and
vomiting, which are usually mild to moderate in severity and only
occasionally lead to premature discontinuation of tramadol.
[0113] The Ultram.RTM. and Tramal.RTM. labels contain several
warnings and precautions regarding use of tramadol. The risk of
most of these potential adverse events can be minimized by
decreasing the dose or excluding use of tramadol in subjects with
risk factors associated with these known, rare adverse events.
Tramadol metabolism is reduced in the setting of advanced cirrhosis
and renal clearance of both tramadol and its metabolites is reduced
in individuals with creatinine <30 mL/min. Thus, the dose of
tramadol should be reduced by half or the interval doubled in these
populations. Dosage adjustment is also recommended in individuals
>75 years of age as they have reduced drug clearance. Tramadol
is metabolized by CYP2D6 and CYP3A4; thus, drugs that are
inhibitors or inducers of these enzymes can alter tramadol
metabolism, resulting in decreased efficacy and/or increased risk
of seizures or other adverse effects. Tramadol is associated with a
low risk for respiratory depression, which is increased in the
presence of other opioids, anesthetic agents and other CNS
depressants, including alcohol. Respiratory depression due to the
opioid activity of tramadol can be reversed with naloxone. Naloxone
should be used cautiously as it can potentiate seizures when
administered with tramadol. The full range of
allergic/hypersensitivity reactions have been reported in
association with tramadol administration, including serious and
rarely fatal anaphylactoid reactions.
[0114] Potentially life-threatening serotonin syndrome may occur
with tramadol products with concomitant use of serotonergic drugs
such as SSRIs, tricyclic antidepressants, monoamine oxidase
inhibitors and triptans.
[0115] Tramadol use, particularly with high doses, has been
associated with seizures, and the risk of seizures is increased in
the presence of drugs that reduce seizure threshold, head trauma or
prior history of seizures.
[0116] Human studies evaluating the abuse potential of tramadol,
administered via IV or PO routes, have also been conducted (Epstein
et al., 2006). During the initial dose-ranging studies, seizure was
observed following a tramadol dose of 700 mg IV administered over 1
minute and 300 mg IV delivered over 2.5 minutes. No seizures were
observed with a tramadol dose of 200 mg IV administered over 5
minutes. The authors hypothesized that toxicity is likely to limit
abuse of high doses of IV tramadol. In a subsequent study involving
10 experienced opioid abusers, tramadol (100 and 200 mg IV),
morphine (10 and 20 mg IV) and placebo were administered over 5
minutes. The endpoints in the study were subjective; the extent to
which subjects "liked" the effects of the drugs, as well as their
ability to produce effects common to morphine and benzadrine
(assessed by the Addiction Research Center Inventory-Morphine
Benzadrine Group [ARCI-MBG] scale). Tramadol and morphine
significantly increased ratings of "feel drug effect" compared to
placebo. However, neither dose of tramadol increased ratings on the
"liking" or ARCI-MBG scale or on any other subjective measure of
opiate-like effects. In contrast, morphine 10 and 20 mg doses
significantly increased ratings of "liking" and the morphine 20 mg
dose increased ratings on the ARCI-MBG scale. Thus, tramadol
administered via the parenteral route (IV or IM) is unlikely to be
associated with the subjective morphine-like and positive mood
effects typical of abuse and addiction.
[0117] In accordance with the present invention, it is desirable to
provide an intravenous dosing regimen of tramadol which at
steady-state provides a plasma concentration with respect to Cmax
that is similar or equivalent to the steady-state Cmax provided by
a 100 mg oral tramadol dose given every 6 hours would be desirable
and would be safer and have less likelihood of significant side
effects than, e.g., the administration of 100 mg of tramadol
intravenously administered every 6 hours (i.e., same dose and
dosing interval as the oral reference standard, Ultram.RTM.. It is
further believed that it would desirable for such an intravenous
dosing regimen(s) to provide a steady-state trough plasma level of
tramadol (e.g., Cmin) which is at least as high as the steady-state
trough level provided by a 100 mg oral tramadol dose given every 6
hours. The steady-state Cmax of the 100 mg oral dose of tramadol
administered every 6 hours is about 736 ng/mL. For purposes of the
present invention, a similar or equivalent Cmax provided by an
intravenous tramadol dosing regimen would provide a Cmax within the
range from about 80% to about 125% of the steady-state Cmax of the
100 mg oral tramadol administered every 6 hours (e.g., 736 ng/mL;
or e.g., from about 588.8 ng/mL to about 920 ng/mL). It is
especially preferred that the steady-state Cmax of the dosing
regimen(s) of the present invention do not exceed the concentration
provided by 100 mg oral tramadol administered every 6 hours, at
steady-state (e.g., about 701 ng/mL) by more than 15% or more than
about 10%. The co-administration of the acetaminophen in effective
amounts, e.g., as described herein, is believed to further provide
a synergistically improved analgesia than the dose of tramadol
alone, and allows for less tramadol to be administered than would
otherwise be required to treat pain in the human patient.
[0118] U.S. Pat. No. 9,693,949 (hereby incorporated by reference in
its entirety) describes a method of administering tramadol for
treating pain in a human patient(s) via an intravenous dosing
regimen comprising intravenously administering a first dose of
tramadol to a human patient(s) in an amount of about 50 mg;
intravenously administering a second dose of tramadol to the human
patient(s) in an amount of about 50 mg at about 2 hours after the
first dose; intravenously administering a third dose of tramadol to
the human patient(s) in an amount of about 50 mg at about 2 hours
after the second dose; and thereafter intravenously administering
additional doses of tramadol to the human patient(s) in an amount
of about 50 mg tramadol at dosage intervals of about 4 hours, until
the patient no longer requires treatment with tramadol, wherein the
tramadol is tramadol base or a pharmaceutically acceptable salt of
tramadol. By virtue of this state-of-the-art dosing regimen,
tramadol is intravenously administered seven times on day one of
therapy and six times a day thereafter. Thus, as per the above, the
'949 patent teaches the intravenous administration of about 350 mg
tramadol on day 1 and 300 mg tramadol on day 2 and onward. This is
in comparison to the dosing regimen of the present invention,
wherein the amount of intravenous tramadol given on a daily basis
is about 240 mg. Likewise, with respect to ketorolac, the dose
administered via the present invention on a daily basis will be
from about 10 mg to about 120 mg, and in certain preferred
embodiments from about 40 mg to about 120 mg per day, as currently
approved for administration in the U.S. It is believed that three
is no IV tramadol dosage regimen of 60 mg tramadol administered
every 6 hours approved or use anywhere in the world.
[0119] In the present invention, the co-administration of
acetaminophen at the same dosage interval as the tramadol (e.g.,
about every 6 hours), allows for the administration of less
tramadol while preferably achieving the same or even better
efficacy because of synergistic and non-overlapping mechanisms,
despite the reduction in doses of each drug.
[0120] A further benefit of intravenous administration of tramadol
with an NSAID having a similar half-life (e.g., ketorolac) is that
the dosing of tramadol and ketorolac may be simultaneous.
[0121] By virtue of the present dosing regimen comprising 60 mg IV
tramadol every 6 hours, the maximum plasma concentration (Cmax) of
the tramadol rapidly approaches the maximum concentration found at
steady-state with respect to a dosing regimen of 100 mg tramadol
HCl administered orally every 6 hours. The Cmax obtained after a
number of doses of 60 mg IV tramadol (e.g., after the fourth,
fifth, sixth or seventh dose) is approximately the same as the Cmax
at steady-state for a dosing regimen of 100 mg tramadol HCl
administered orally every 6 hours. However, in contrast, the oral
tramadol dosing regimen takes considerably longer (Cmax.sub.44-48)
to reach that maximum tramadol plasma concentration. As discussed
in Example 5 of the '949 patent, the Cmax of the 50 mg IV tramadol
dosing regimen is about 736 ng/mL.+-.152 and is approached during
the third dose (see, e.g., Example 5, Table 11 and FIGS. 11-12),
whereas the Cmax of tramadol for the oral 100 mg dosing regimen is
about 701 ng/ml.+-.178 and occurs at 42-48 hours after the first
oral dose is administered (see, e.g., Example 5, Table 11 and FIGS.
9 and 12). Moreover, in this embodiment the trough levels (plasma
concentrations of tramadol) also much more rapidly reach a level
similar to the trough levels at steady-state for the oral 100 mg
every 6 hours dosing regimen. It is believed that the fact that
(for the 60 mg IV dosing regimen) peak and trough plasma levels
similar to steady-state levels found for the oral 100 mg q6h dosing
regimen are reached at a such an earlier time may translate into
improved efficacy (pain relief) for the patients.
[0122] It is further believed that the intravenous dosing regimen
of the invention, e.g., as a slow push of a therapeutically
effective dose of tramadol contained in a bag over a time period
from about 10 to about 20 minutes, preferably about 15 minutes,
will provide added safety with respect to the above-mentioned
potential adverse events and others, and will provide lower
incidence of side effects associated with tramadol administration.
It is further believed that the intravenous dosing regimen of the
invention where a therapeutically effective dose of tramadol is
administered to a human patient(s) over a time period from about 24
hours to 48 hours in much slower infusion will also provide these
benefits.
[0123] The intravenous tramadol formulation in accordance with the
invention typically includes tramadol in the form of its
hydrochloride salt. However, one of ordinary skill in the art will
appreciate that other forms of tramadol may be used, including but
not limited to all pharmaceutically acceptable salts of tramadol.
Such pharmaceutically acceptable salts may include, but are not
limited to, metal salts such as sodium salt, potassium salt, secium
salt and the like; alkaline earth metals such as calcium salt,
magnesium salt and the like; organic amine salts such as
triethylamine salt, pyridine salt, picoline salt, ethanolamine
salt, triethanolamine salt, dicyclohexylamine salt,
N,N'-dibenzylethylenediamine salt and the like; inorganic acid
salts such as hydrochloride, hydrobromide, sulfate, phosphate and
the like; organic acid salts such as formate, acetate,
trifluoroacetate, maleate, tartrate and the like; sulfonates such
as methanesulfonate, benzenesulfonate, p-toluenesulfonate, and the
like; amino acid salts such as arginate, asparginate, glutamate and
the like.
[0124] It is contemplated that with respect to the inventive
methods for the intravenous administration of tramadol as described
herein, other analgesics, preferably opioid analgesics, may be used
to treat postoperative pain in the patient(s), as well. It is
particularly contemplated that one or more opioid analgesics will
be administered post-surgically to the patient as rescue medicine
in order to treat breakthrough pain that the patient may
experience.
[0125] The term "opioid analgesic" refers to all drugs, natural or
synthetic, with morphine-like actions. The synthetic and
semi-synthetic opioid analgesics are derivatives of five chemical
classes of compound: phenanthrenes; phenylheptylamines;
phenylpiperidines; morphinans; and benzomorphans, all of which are
within the scope of the term. Opioid analgesics which are useful in
the present invention include all opioid agonists or mixed
agonist-antagonists, partial agonists, including but not limited to
alfentanil, allylprodine, alphaprodine, anileridine,
benzylmorphine, bezitramide, buprenorphine, butorphanol,
clonitazene, codeine, desomorphine, dextromoramide, dezocine,
diampromide, diamorphone, dihydrocodeine, dihydromorphine,
dimenoxadol, dimepheptanol, dimethylthiambutene, dioxaphetyl
butyrate, dipipanone, eptazocine, ethoheptazine,
ethylmethylthiambutene, ethylmorphine, etonitazene, fentanyl,
heroin, hydrocodone, hydromorphone, hydroxypethidine, isomethadone,
ketobemidone, levorphanol, levophenacylmorphan, lofentanil,
meperidine, meptazinol, metazocine, methadone, metopon, morphine,
myrophine, narceine, nicomorphine, norlevorphanol, normethadone,
nalorphine, nalbuphene, normorphine, norpipanone, opium, oxycodone,
oxymorphone, papaveretum, pentazocine, phenadoxone, phenomorphan,
phenazocine, phenoperidine, piminodine, piritramide, propheptazine,
promedol, properidine, propoxyphene, sufentanil, tilidine, mixtures
of any of the foregoing, salts of any of the foregoing, and the
like.
[0126] In certain preferred embodiments, opioid analgesics include
morphine, oxycodone, codeine, dihydrocodeine, diacetylmorphine,
hydrocodone, hydromorphone, levorphanol, oxymorphone, alfentanil,
buprenorphine, butorphanol, fentanyl, sufentanyl, meperidine,
methadone, nalbuphine, propoxyphene and pentazocine or
pharmaceutically acceptable salts thereof. In certain preferred
embodiments, the opioid agonist is morphine. Equianalgesic doses of
these opioids are generally known to those persons having ordinary
skill in the art.
[0127] In certain embodiments, the patient's need for additional
analgesic treatment beyond the intravenous tramadol may be
ascertained via the use of a surrogate measure of pain. Pain rating
scales are used in daily clinical practice to measure pain
intensity. The commonly used measurement scales include the Visual
Analog Scale (VAS), the Graphic Rating Scale (GRS), the Simple
Descriptor Scale (SDS), the Numerical Rating Scale (NRS), and the
Faces Rating Scale (FRS). All of these scales have been documented
as being valid measures of pain intensity. The three scales most
commonly used in the U.S. are the numerical, word and faces scales.
One preferred pain rating scale is the visual analog scale (VAS), a
10 cm. vertical or horizontal line with word anchors at the
extremes, such as "no pain" on one end and "pain as bad as it could
be" at the other. The patient is asked to make a mark along the
line to represent pain intensity.
[0128] Alternatively, the graphic rating scale (GRS) is a variation
of the visual scale which adds words or numbers between the
extremes. Wording added might include "no pain", "mild", "severe".
The descriptor scale (SDS) is a list of adjectives describing
different levels of pain intensity. For example pain intensity may
be described as "no pain", "mild", "moderate" or "severe". The
numerical pain rating scale (NPRS) refers to a numerical rating of
0 to 10 or 0 to 5 or to a visual scale with both words and numbers.
The patient is asked to rate the pain with 0 being no pain and 10
being the worst possible pain. The faces scale was developed for
use with children. This scale exists in several variations but
relies on a series of facial expressions to convey pain intensity.
Grouping patients' rating of pain intensity as measured with a
numerical scale ranging from 0 to 10 into categories of mild,
moderate, and severe pain is useful for informing treatment
decisions, and interpreting study outcomes,. In 1995, Serlin and
colleagues (Pain, 1995, 277-84) developed a technique to establish
the cut points for mild, moderate, and severe pain by grading pain
intensity and functional inference. Since then, a number of studies
have been conducted to correlate the numerical scales, for example
the NPRS, with cutpoints related to levels of pain intensity.
Common severity cutpoints are (1 to 4) for mild pain, (5 to 6) for
moderate pain, and (7 to 10) for severe pain.
[0129] Surrogate measures of opioid efficacy (analgesia) include
sedation, respiratory rate and/or pupil size (via pupillometry),
and visual analogue scale ("VAS") for "drug effect". The Sum of
Pain Intensity Differences (SPID) through 48 hours post first dose
(SPID48) at rest may be used as a primary measure of efficacy.
[0130] The intravenous tramadol/ketorolac dosing regimens of the
invention may be used in the in the hospital or day hospital
setting and therefore administered by medical staff. The tramadol
hydrochloride injection for intravenous use and its dosing regimen
can fill an important need in addition to tramadol (e.g.,
ULTRAM.RTM.) tablets and tramadol (e.g., ULTRAM.RTM. ER)
extended-release tablets by providing this safe and effective
injectable analgesic with a novel mechanism of action (.mu.-opioid
agonist and monoaminergic reuptake inhibition) for use in the acute
post-operative setting. These dosing regimens may be used, e.g.,
for all types of surgery, including orthopedic surgery (e.g., total
knee replacement, bunionectomy) or soft tissue surgery (e.g.,
elective abdominoplasty).
Conclusion
[0131] All patents and publications identified in the above
paragraphs are hereby incorporated by reference in their
entireties. It will be readily apparent to one of ordinary skill in
the relevant arts that other suitable modifications and adaptations
to the methods and applications described herein are suitable and
may be made without departing from the scope of the invention or
any embodiment thereof. While the invention has been described in
connection with certain embodiments, it is not intended to limit
the invention to the particular forms set forth, but on the
contrary, it is intended to cover such alternatives, modifications
and equivalents as may be included within the spirit and scope of
the invention as defined by the following claims. All of the
patents and publications cited herein are hereby incorporated by
reference.
* * * * *