Tramadol (Ultram)

Tramadol (Ultram)

What is Tramadol used for?

Chemical structure of Tramadol (opioid analgesic drug)Tramadol (pronounced Tra-ma-dole), also known by brand names Ultram, Ultram ER, Ralivia, Dromodol, Ryzolt, ConZip, Rybix ODT and FusePaq Synapryn, is commonly prescribed to treat neuropathic pain and various disorders characterised by tender, painful and stiff muscles. The medication, which is classified as an opioid analgesic, is typically used to alleviate pain that ranges between moderate to moderately severe, as well as that which is experienced following a surgical procedure.

Tramadol has proved beneficial for those suffering ongoing (chronic) pain. The medication effectively works with the body’s central nervous system in order to relieve pain. Used for long-term treatment, this medication has been noted as potentially habit-forming, resulting in dependence in both a mental and physical capacity. Physical dependency can lead a variety of side-effects, especially when discontinued. The medication itself, is not classified as a narcotic, however. As dependency is a risk factor, Tramadol is classified as a controlled substance.

The medication is effectively a ‘centrally acting synthetic’ and works by inducing the release of serotonin in the brain, and inhibiting the reuptake of norepinephrine. This can create a ‘narcotic-like’ pain relief effect, which can lead to dependency. Serotonin and norepinephrine are the two chemicals in the brain directly linked with mood, as well as responsiveness to pain in the body.

The medication is mostly made up (about 80%) of ingredients inhibiting the reuptake of chemicals in the brain and the remaining 20% being pain-relieving components. The pain-reliving ingredients come from opioids, which are less likely than many other painkiller products to cause dependency. These include morphine, hydrocodone and oxycodone. Although a low percentage in terms of habit-forming content (opioids), the medication still carries a dependency risk for some individuals (this addiction usually develops through misuse).

Often, a doctor may consider Tramadol when other pain-relieving medications have not proved all that effective. This medication is only available through prescription from a licensed medical practitioner in the following dosage forms (to be taken orally):

  • Tablet (including disintegrating or extended-release forms)
  • Suspension
  • Capsule (extended-release)

Tramadol may be prescribed for a variety of medical conditions (not all of which are primarily associated with physical pain) that may respond favourably to the anti-inflammatory and non-steroidal effects of this drug, provided a medical doctor feels it appropriate. The effects of both opioid and serotonergic ingredients can be effective for treating both the physical and psychological components of pain (in acute and chronic forms). These can include:

  • Diabetic neuropathy: A diabetic person often experiences nerve damage in the body, mainly affecting their legs and feet. Nerve damage can cause considerable pain, as well as numbness. This can result in possible problems developing in the heart, blood vessels, digestive system and urinary tract. Symptoms of pain can range from mild to severe, and sometimes become life-threatening. Tramadol can be useful in managing chronic pain for those undergoing treatment for diabetes.
  • Migraine: Migraine headaches that are accompanied by visual disturbances (known as migraine with aura) can be an intensely painful experience. Tramadol can provide effective relief for pain associated with this type of headache.
  • Fibromyalgia: A chronic condition that is widespread in the body, pain levels vary in intensity throughout the musculoskeletal system. Some relief from pain and tender areas in the body can be achieved with this medication.
  • Multiple Sclerosis (MS): An unpredictable and disabling condition whereby the immune system ‘attacks’ the protective sheath or covering of the body’s nerves, resulting symptoms of MS include pain and muscle spasms. Symptoms such as these can lead to problems with mobility. Treatment of multiple sclerosis with Tramadol can considerably alleviate moderate to severe discomfort.
  • Anxiety, depression and obsessive-compulsive disorder (OCD): Those who suffer from constant symptoms of nervousness, worry, fear, hopelessness, apprehension and uneasiness can benefit from the chemical adjustments the taking of this medication can achieve. A medical doctor will prescribe this medication for these conditions with great care and consideration, especially if a person suffers from extreme forms of these disorders or displays addictive behaviours.
  • Postherpetic neuralgia (pronounced post-hur-PET-ik noo-RAL-juh): This condition often develops as a complication of the Varicella Zoster virus (causing chickenpox and shingles). The condition is associated with damage to nerve fibres and the skin which can cause a burning pain.
  • Reflex sympathetic dystrophy (RSD): Damage to the reflex sympathetic nervous system in the body can result in a burning-like pain (often described as a pain that feels like fire). Tramadol can help to alleviate this pain.
  • Restless legs syndrome (RLS): A condition characterised by an uncontrollable urge to move legs, a sufferer often experiences ‘pins and needles’, itching and creepy crawly sensations which can be alleviated with Tramadol.

Precautions and considerations for taking this medication

Tramadol is not to be taken unless strictly recommended and prescribed by a medical doctor. Your doctor will have done a thorough assessment of your specific condition before determining treatment with Tramadol as an option. He or she will weigh up benefits against potential complications and likely side-effects before prescribing the use of this drug. If favourable, your doctor will recommend a prescription with strict instructions.

The nature of side-effects and possible complications will also prompt your doctor to inform you in detail as to what risks the medication may carry. Your doctor should advise you to take note of all necessary precautions, risk factors and possible side-effects. Before issuing a prescription, he or she will have assessed a variety of possible risk factors as well.

Doctor examining senior female patient. Assessment will include the following potential risk factors:

  • Allergies: Inactive ingredients in Tramadol can cause various complications and allergic reactions. Your doctor will wish to know if you have any known allergies, or experienced adverse reactions in the past.
  • Medical history and health conditions: Yours and that of close relatives may be required so that your doctor can assess potential risk factors. Certain medical conditions may prohibit the use of Tramadol altogether, or prompt your doctor to prescribe with caution. High on the list are a history of (or current) brain and nervous system disorders, such as seizures, epilepsy, Parkinson’s disease, head injuries or tumours, problems associated with breathing and respiratory function, such as chronic obstructive pulmonary disease (COPD), asthma, respiratory depression, slow breathing (hypoventilation) or sleep apnoea, organ diseases, such as those of the kidney or liver, mental or mood disorders, such as depression or bipolar disorder (including suicidal thoughts or attempts), addiction or substance abuse (drugs and alcohol), genetic conditions such as metabolic disorder and intestinal and digestive problems, such as diarrhoea, constipation and bladder control problems (urination), stomach upsets, gallbladder disease and pancreatitis. If you are treating migraine headaches, hormonal problems, or serious infections, these also need to be disclosed to your doctor. Tramadol may either worsen symptoms associated with these conditions or adversely interact with medication already being taken to treat them.
  • Use of other medications and supplements: Your doctor will wish to list all over-the-counter and prescription medications, as well as any supplements and herbal products you are taking before prescribing this medication. If you are using any type of narcotic pain medication, antidepressants and / or other mental illness drugs (including antipsychotic medications and monoamine oxidase inhibitors / MAOIs), sedatives or tranquilisers, muscle relaxers, antihistamines, those used to prevent blood clots or seizures, antibiotics, antifungal medications, drugs treating heart and blood pressure problems or HIV/AIDS, or anti-nausea / vomiting drugs, you must disclose this to the doctor considering Tramadol for treatment (if they have not prescribed these for you or are not aware of your medical / treatment history).
  • Age: Seniors (65 years of age and older) are known to be more sensitive to some side-effects of this medication and can experience adverse symptoms of drowsiness, dizziness, confusion, fainting, stomach upset, constipation, age-related liver and heart problems, as well as slow or shallow breathing. As a result, dosages for seniors (often recommended at lower strengths) will be handled with care and monitored throughout a treatment period. Absolute safety and efficacy in children younger than 16 has not been established, and as a result a doctor may prescribe Tramadol with caution.
  • Pregnancy and breastfeeding (nursing mothers): A doctor will take into consideration all females of childbearing age before prescribing this medication. He or she will advise all risks and benefits during an initial consultation, especially if a woman intends to fall pregnant and bear a child of her own. It is strongly advised that if you are pregnant you disclose this to your doctor before accepting a prescription for this medication, especially during the first trimester. A doctor will only consider treatment with Tramadol during pregnancy if the benefits outweigh potential risk factors. There is a risk of birth defects which can affect a developing foetus during the first two months of pregnancy. High doses of this medication towards the end of gestation can also place an unborn baby at risk. A new-born baby can experience withdrawal-like symptoms following birth, which include irritability, unexplained or persistent crying, diarrhoea, vomiting, difficulty with feeding and slow or shallow breathing. If pregnant and a doctor assesses a need for this medication, doses will be strictly controlled (administering the lowest effective dose) for the shortest possible time period in order to avoid infant withdrawal symptoms. The medication will also be carefully considered before being prescribed when a patient is nursing (breastfeeding). Tramadol ingredients may pass through breast milk and thus affect a new-born baby, causing unexplained sleepiness, feeding difficulties and breathing problems. A baby that is born with habit-forming (withdrawal) symptoms may require treatment for several weeks. In severe instances, side-effects experienced by a baby can be life-threatening.

Medication interactions – the importance of disclosing all medications and medical conditions

If during the doctor’s assessment it is determined that you have recently taken or are taking certain medications, your doctor will require specific information on these so that he or she can assess whether Tramadol can safely be prescribed.

The taking of multiple medications can cause adverse reactions and side-effects. This must be carefully considered so as to avoid potentially serious medical complications. Certain medications will never be allowed to be used at the same time for this reason. In other instances, your doctor will assess all that you are taking, and how necessary each is for the treatment of your overall condition. Dosages for each medication may be adjusted to ensure the least risk of side-effects. Alternatively, medications may be changed to achieve the least risk.

All necessary medication will be discussed with you in detail, ensuring that you are well aware of all benefits, and possible side-effects and complication risks.

One of the main concerns regarding multiple medication treatment is a potentially serious condition known as serotonin syndrome. This can happen when excess nerve cell activity occurs and there is too much (an accumulation of) serotonin production in the body. The condition is potentially fatal and can be triggered within a matter of hours after taking a new medication or an increased dosage.

Your doctor may also bring up other related interactions which can occur when taking Tramadol. If you are taking other medications at the same time, you may be advised to take some with food and others on an empty stomach. This is to alleviate potential discomfort (mild side-effects).

Your doctor may stress the importance of limiting or avoiding the use of alcohol or tobacco while taking medications. He or she will likely outline potential interaction the use of these substances will have at the time of taking your medications.

Tramadol should not be taken with the following medications as these may cause severe interactions:

  • Monoamine oxidase inhibitors (MAOIS)
  • Monoamine oxidase-B (MAO-B) inhibitors (Rasagiline – Azilect, Selegiline - l-deprenyl)
  • Opioid Analgesics (Propoxyphene -Darvon)
  • Opioid Antagonists (Naltrexone – Revia, Vivitrol)
  • Serotoninergic Agents (Dapoxetine – Westoxetin and Priligy)

Other serious interactions may occur with:

  • 5HT-1D Agonists (Triptans)
  • Antibiotics (Linezolid – Zyvox, Zyvoxid)
  • Anticonvulsants (Carbamazepine – Tegretol)
  • Chronic opioids (Butorphanol, Buprenorphine, Nalbuphine)
  • Opioid analgesics (Tapentadol – Tapal, Nucynta, Palexia, Codeine)
  • Sodium Oxybate
  • Tricylic compounds

Other risk factor precautions

Your doctor will also likely advise the following precautions to keep in mind once treatment commences:

  • At the start of treatment, or when dosages are adjusted, you may experience drowsiness or dizziness. Your doctor will advise you to take precautions when it comes to activity that requires alertness, such as driving or performing certain activities or operating machinery.
  • You may also be advised to limit or avoid alcohol consumption altogether. Consuming alcohol can worsen symptoms of your condition or aggravate those associated with side-effects. In severe instances, the combination of this medication with alcohol consumption can be life-threatening, especially if taking other medications as well.
  • If at any stage during treatment you require surgery or dental procedures, you must advise your use of this medication to all attending professionals. If you are taking more than one medication (including supplements and herbal products), you will need to disclose this as well.

How to use Tramadol

Your doctor will stress the importance of using this medication as directed. As with the taking of any medication, this drug also carries some risk of side-effects during treatment and for a period of time following discontinuation.

Hands holding pills to be swallowed with water.

Correct dosages

It is very important that you do not take doses that are higher than your doctor has prescribed, more frequently than recommended or for a longer period of time than your doctor has authorised. It is also very important that you do not share this medication with anyone else. Dosages must be specifically recommended by a licenced medical practitioner following a thorough medical assessment (on an individual basis). A recommended treatment programme may work for you but not for another.

The medication leaflet or guide does list standard doses which are recommended as a result of extensive clinical studies. Your recommended dosages may differ from this. It is very important that you do not assume that your dosage is incorrect and change it on your own. There are specific reasons why your doctor has given you certain doses. If you are unsure, consult your doctor before commencing treatment and discuss any concerns as soon as possible. He or she will provide as much clarity as you need in order to use the medication as safely as possible for your required purpose.

The number of daily doses may vary as well, and largely depends on the strength of the medication. Your specific medical condition will also determine the number of required daily doses, the time period between doses and the length of time necessary for treatment.

It may take a period of time before the medication will appear to take effect. You doctor will advise you to take the medication exactly as directed even if it takes some time for you to start feeling better. Do not assume that you need a higher dose for the medication to take effect. Any dosage changes must be made by your doctor only. He or she will also advise that you do not discontinue use of the medication on your own, especially once it becomes apparent that it is working for your condition. It is not advisable to use the medication on a ‘stop and start again’ basis.

For the management of chronic pain, a doctor may prescribe the following average doses:

  • Extended-release tablets: Adults may be recommended to take 100 milligrams (mg) a day to start treatment. Doses may be gradually increased by a doctor as needed, but will generally not exceed 300 mg a day. Extra caution will be taken with prescribing doses for children and may depend on medication strength and the condition being treated.
  • Oral dosage tablets: Teenagers (16 years of age and over) and adults may be prescribed 50 to 100 mg every 4 to 6 hours to begin a treatment period. Doses may gradually be increased as needed, but will usually not exceed 400 mg a day. A doctor will prescribe doses for children under the age of 16 with caution and taking into account the medical condition being treated.

For the management of moderate to severe pain, a doctor may prescribe the following average doses:

  • Oral dosage disintegrating tablets: Adults and teenagers older than 16 years of age may be recommended to take between 50 and 100 milligrams (mg) every 4 to 6 hours to start treatment. Doses may be gradually increased by a doctor as needed, but will generally not exceed 400 mg a day. Extra caution will be taken with prescribing doses for children under the age of 16 and may depend on medication strength and the condition being treated.
  • Oral dosage tablets: Teenagers (16 years of age and over) and adults may be prescribed 25 mg at the beginning of a treatment period, to be taken each day in the morning. Doses may gradually be increased as needed, but will usually not exceed 400 mg a day. A doctor will prescribe doses for children under the age of 16 with caution and taking into account the medical condition being treated.

*These average dosages may vary according to multiple factors your doctor determines as necessary for your specific condition and those which best benefit you for effective treatment.

How to take your medication correctly

Your doctor will also advise the best ways to take your medication before your treatment commences. Some instructions your doctor may give you include:

  • Ensure that your hands are dry when handling / taking disintegrating tablets.
  • Ensure to only open a blister pack of tablets when you are ready to start taking your medication.
  • Try not to push the tablet through the foil of the blister pack. It is better to peel back the foil, exposing one table at a time, to be taken as needed.
  • Ensure that you do not chew, break or crush your tablets when taking the medication. They are to be swallowed whole. Disintegrating tablets should dissolve quickly once placed on the tongue inside your mouth. Once it melts away, sip water and swallow.
  • Extended – release tablets should be swallowed whole with liquid (not broken, emptied of contents, crushed or chewed). The medication is also intended for oral use only (by mouth) and should not be inhaled, injected or diluted. Taken in these ways can lead to life-threatening side-effects, complications or overdose.
  • If you miss a dose, you must take care not to double dose as this can lead to adverse side-effects. If the missed dose is close to the time it should have been taken, ensure to take your medication. If the missed dose is closer to the time of the next one, it is advisable to skip it and assume your regular schedule.
  • You should store your medication in a closed, dry container or cupboard away from any light, moisture or heat. This medication is best stored at room temperature and should never be frozen. Your doctor may also strongly advise that you take care to store out of reach of others, particularly children and pets.
  • No medication should be kept beyond the treatment period. Your doctor will advise all authorised doses and assist you with safely discontinuing the medication. Any medication left over (or expired) should not be stored, shared with anyone else or used (without your doctor’s recommended permission). Your doctor can advise the best ways to dispose of any unused or expired medication.

Side-effects of Tramadol usage

Common side-effects

The body will take some time to adjust to the use of this medication. As such, you are likely to feel some level of discomfort when you begin treatment (use of the medication). Side-effects may vary from person to person. Not everyone on the medication will experience all recorded symptoms. The most common side-effects to be mindful of include:

  • Skin issues, such as rash, itchiness or sweating
  • Muscle and join aches (or pain) and body weakness
  • Abdominal discomforts, such as nausea, vomiting, stomach pain, diarrhoea and constipation
  • Heartburn and indigestion
  • Mood changes and feelings of discouragement and sadness (depression), agitation or irritability, anxiety (or nervousness) and a general loss of interest or pleasure
  • Restlessness
  • Coughing
  • Dry mouth
  • Drowsiness
  • Feeling flushed (warm sensations) or unusually cold (including shivering)
  • Redness of the face, neck, upper chest or arms
  • Headache
  • Fever
  • A runny nose (or stuffiness)
  • Sore throat
  • General malaise (feeling unwell)
  • Loss of appetite
  • Sweating
  • Concentration problems

Less common side-effects

Many of the below may not require medical intervention and can subside as your body begins to adjust to the medication in the system. It is a good idea to be well aware of these side-effects and inform your doctor if you find them unmanageable, as he or she can assist with either reducing severity or preventing future occurrences altogether.

  • Severe headaches
  • Severe cough
  • Swollen joints
  • Changes to weight (gain or loss)
  • Confusion or memory loss
  • Dizzy spells (falling down) and problems with balance (affecting your ability to walk properly)
  • Bloating or abdominal (stomach) fullness
  • Increase in blood pressure
  • Blurry vision
  • Touch sensation abnormalities, including tingling, numbness or weakness (especially in the hands, feet, toes, fingers or facial area)
  • Pale or bluish colour in the hands and feet
  • Urination difficulties or an increased urge (feeling) to urinate
  • Increased heart rate, or a rapid or irregular heartbeat
  • Gaseous abdominal discomfort
  • Recurrent fever
  • Body chills or sweating
  • Discomfort or pain in the jaw, neck, back (or lower back), arms, legs, calves or heals

Rare side-effects

Some side-effects may affect a very small percentage of Tramadol users. If any of the below are experienced, you must seek medical assistance as soon as possible:

  • Chest pain and indigestion
  • Blood in urine
  • Dark urine
  • Convulsions or seizures
  • Trembling hands and feet
  • Yellowing of the whites of the eyes and skin (jaundice)
  • Fainting
  • Blisters forming underneath the skin
  • Severe cramping and nausea
  • Shortness of breath
  • Severe skin inflammation (redness and swelling), as well as itching or hives
  • Distorted sense of reality (hearing, seeing or feeling things that aren’t there)
  • A weak (or absent) pulse in the legs
  • Inability to perform routine (daily) tasks

Signs of overdose

If any of the below symptoms are experienced, you must seek medical care immediately.

  • Change (or loss) of consciousness
  • Non-responsiveness or a notable decrease in awareness
  • Breathing difficulties (including shortness of breath)
  • Pinpointed pupils
  • Loss of muscle tone
  • Severe fatigue or sleepiness (including difficulty waking up)
  • An irregular or slow heartbeat
  • Hallucinations
  • Fainting or seizures and convulsions
  • Coma

Any sign of overdose must be taken seriously and attended to by a medical professional as soon as possible. If severe, overdose can be life-threatening, as can symptoms associated with misuse of this medication. Abuse of this medication can lead to the body building a tolerance over time (which can be ‘satisfied’ with increased doses). High doses of the medication in the bloodstream can lead to overdose and cause severe complications such as coma or death.

Discontinuation and side-effects

As with the initial stages of treatment, the body requires some time to adjust at the tail end as well. When you discontinue use of Tramadol, it’s not uncommon to experience any of the aforementioned side-effects in varying degrees of intensity.

Before treatment commences, it is a good idea to discuss with your doctor all side-effects to be mindful of for the entire duration of your recommended treatment period. If at any stage during treatment you feel uncomfortable or concerned, it is strongly advisable to consult your doctor as soon as possible. Your doctor will be able to help you better manage your side-effects or alleviate potential problems with medical treatment.

Withdrawal symptoms

Discontinuation will come with discomfort as the body adjusts to the lack of medication. Taking Tramadol continuously, even for a period of a few weeks, stimulates a tolerance in the body as chemical production is altered. The brain adapts to the presence of the drug, and adjusts chemical production accordingly.

With discontinuation, the brain attempts to self-regulate chemical production which leads to the development of adverse reactions or withdrawal symptoms. Some of which can be similar to those experienced when discontinuing other medications used for antidepressant purposes.

To best manage this, your doctor will likely taper dosages towards the end of your treatment period, effectively reducing risk of severe reactions and discomfort. Sudden discontinuation will ‘shock’ the body’s system and lead to potentially severe side-effects, which can in turn result in serious complications. Serious withdrawal symptoms include panic attacks, hallucinations and severe anxiety.

Tapering will involve a gradual easing off of the medication by reducing doses over time. Withdrawal symptoms which can be experienced include:

  • Nausea and vomiting
  • Stomach upsets, cramping and diarrhoea
  • Headaches
  • Loss of appetite or cravings
  • Restlessness, agitation, irritability, anxiety, depression or mood swings
  • Sweating
  • Confusion
  • Insomnia or problems with sleeping (including nightmares)
  • Blurred vision
  • Muscle pain
  • Tingling sensations
  • Dizzy spells
  • Shaking or tremors
  • Pins and needle sensations

Withdrawal symptoms can be experienced within a matter of hours following discontinuation of the medication and linger for several weeks. Your doctor will be well aware of the symptoms to be expected during this time and will carefully take into consideration the length of time you have been using the medication. The longer you are on the medication, the more time it may take to effectively and safely ease off the drug. Dosage strength and frequency will also factor in to this.

If tapered off safely, you can expect to experience the onset of general withdrawal symptoms in varied levels of intensity for up to 14 days (2 weeks). Symptoms typically become milder during this period.

It is best that you never try and detox yourself from use of this medication. Symptoms can be quite uncomfortable to experience are can be better controlled and managed through the supervision (monitoring) of a medical professional. In some cases, treatment with the use of other medications may be advised to help manage discomfort.

Important warnings

As a result of the opioid content, Tramadol does carry a risk of usage abuse which can lead to addiction. With physical pain relief, many find that that the medication (particularly with long-term use) also produces a euphoric effect, which can become difficult to dissociate form. When this happens, the medication can become habit-forming.

Those with addiction problems associated with this medication crave ‘the high’ which can be achieved and in severe instances, can experience hallucinations. Withdrawal symptoms can also be intense for an addicted user.

For this reason, doctors carefully assess a new patient’s addiction risk before prescribing this medication (in any form and strength). If there is a history or alcohol or drug abuse, or attempts of suicide, a doctor may very well opt not to make use of this medication for treatment. A doctor may also opt to dismiss treatment with this medication if any others are already being used for mental illness conditions.

How great a risk is addiction?

Addiction should not be confused with the body becoming settled on the medication. An addiction merely means that the purpose of use has changed (i.e. doses are administered to achieve levels of euphoric relief).

In comparison to other habit-forming medications, Tramadol carries a fairly low risk of addiction due to euphoric effects. Chemically triggered effects in the brain can stimulate feelings of well-being (central nervous system stimulation) as early as a week after commencing regular doses.

A ‘pleasurable high’ which becomes habit-forming is only really achievable when taking the medication in a manner other than that which is safely prescribed. If abused or misused, the body beings to tolerate the substance prompting higher doses in order to achieve ‘the high’. The intensity of the medication’s effects will thus intensify as well, stimulating a dependency.

Misuse and abuse of Tramadol includes injecting, chewing, smoking, snorting, ingesting higher doses and more frequently than prescribed, as well as combining the medication with other drugs (medicinal or illicit) and alcohol consumption.

Your doctor will ensure to only authorise dosage amounts that treat your medical condition and not to recommend excess amounts that can compromise your overall health or lead to a change in need of the drug (i.e. become habit-forming). If you adhere to your doctor’s recommendations, you should not form an addiction to Tramadol.

What else should I take into consideration regarding this medication?

  • Refills: As Tramadol is a controlled substance (classified as a schedule 4 medication), by law, the medication can only be authorised by a licensed medical practitioner with a set number of refills per prescription. In most instances, one prescription can only be refilled up to 5 times within a 6-month period, before a new prescription can be authorised.
  • Medical health insurance: Many medical health insurance providers may have policies which cover the cost of treatment with this medication. Prior authorisation may be necessary. It is advisable to check with your medical health insurance provider before commencing treatment.

 

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