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The formation of M1 is dependent upon CYP2D6 and as such is subject to inhibition, ... In patients with creatinine clearances of less than 30 mL/min, ... a 10- day titration to a daily tramadol hydrochloride dose of 200 mg (50 mg ... as needed for pain relief every four to six hours, not to exceed 400 mg per day . ......

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