A comparison of intramuscular ketorolac with indomethacin suppositories in the treatment of pain after oral surgery

The analgesic effects of 30 mg intramuscular ketorolac were compared with those of rectal indomethacin in 100 mg and 200 mg doses in 66 patients in a single-blinded trial. Pain scores and the incidence of nausea and vomiting were assessed at 30, 60 and 120 minutes postoperatively, at discharge (4 hours) and on the evening of surgery. Area under the curve of pain scores versus time for pain at 30, 60 and 120 minutes postoperatively was significantly lower in the ketorolac group compared to indomethacin 100 mg and 200 mg groups. There were no significant differences in the pain scores at discharge or at home on the evening of surgery. At 60 minutes postoperatively there was significantly more nausea and vomiting in the indomethacin 200 mg group; at all other time-points there was no significant difference between the groups with regard to nausea and vomiting. The power of the study to determine the significance of side-effects between the groups was low.

Intraoperative ketorolac and posttonsillectomy bleeding

OBJECTIVE

To determine the occurrence of posttonsillectomy bleeding in patients who received intraoperative ketorolac tromethamine.

DESIGN

Retrospective analysis.

SETTING

Academic tertiary care center.

PATIENTS

Three hundred eleven patients who underwent tonsillectomy in an 18-month period.

MAIN OUTCOME MEASURE

Occurrence of bleeding complications in patients who received ketorolac during tonsillectomy.

RESULTS

Fifty-eight of 311 patients who underwent tonsillectomy received intraoperative ketorolac with an overall postoperative bleeding rate of 17%. This high rate of bleeding complications compares with 4.4% in the remaining 253 patients who received traditional opioid analgesics.

CONCLUSIONS

Until further controlled studies have been conducted, the use of ketorolac in patients undergoing tonsillectomy should be avoided because of the increased incidence of postoperative bleeding complications.

A comparison of ketorolac with flunixin, butorphanol, and oxymorphone in controlling postoperative pain in dogs

Ketorolac tromethamine, a nonsteroidal anti-inflammatory analgesic, was compared with flunixin and butorphanol for its analgesic efficacy and potential side effects after laparotomy or shoulder arthrotomy in dogs. Sixty-four dogs were randomly assigned to receive butorphanol 0.4 mg/kg body weight (BW) (n = 21), flunixin 1.0 mg/kg BW (n = 21), or ketorolac 0.5 mg/kg BW (n = 22), in a double blind fashion. The analgesic efficacy was rated from 1 to 4 (1 = inadequate, 4 = excellent) for each dog. The average scores after laparotomy were ketorolac, 3.4; flunixin, 2.7; and butorphanol, 1.6. After shoulder arthrotomy, the average scores were ketorolac, 3.5; flunixin, 3.0; and butorphanol, 1.4 (5/11 dogs). As butorphanol was unable to control pain after shoulder arthrotomy, oxymorphone, 0.05 mg/kg BW, replaced butorphanol in a subsequent group of dogs and had a score of 2.0 (6/11 dogs). Serum alanine aminotransferase and creatinine were significantly elevated above baseline at 24 hours postoperatively in dogs receiving flunixin. One dog in each group developed melena or hematochezia. One dog receiving ketorolac had histological evidence of gastric ulceration. We concluded that ketorolac is a good analgesic for postoperative pain in dogs.

Reversible membranous nephropathy associated with the use of nonsteroidal anti-inflammatory drugs

OBJECTIVE

To investigate the frequency of membranous nephropathy associated with nonsteroidal anti-inflammatory drug (NSAID) use and identify associated clinical characteristics.

DESIGN

Retrospective chart review.

SETTING

A large group practice that staffs 2 large teaching hospitals.

PATIENTS

All patients diagnosed as having stage I or early stage II membranous nephropathy by renal biopsy between January 1975 and May 1995.

MAIN OUTCOME MEASURES

Nephrotic syndrome was said to be associated with NSAID use if patients developed nephrotic syndrome while taking an NSAID and if other causes of membranous nephropathy were excluded and a rapid remission of the nephrotic syndrome followed withdrawal of the drug.

RESULTS

Of 125 patients identified with early membranous nephropathy, 29 were taking NSAIDs at the time symptoms of nephrotic syndrome developed. Thirteen of these patients met the criteria for NSAID-associated membranous nephropathy. None of these patients had any evidence of renal insufficiency or significant proteinuria after follow-up periods ranging from 5 months to 13 years. In addition to diclofenac and fenoprofen, which have previously been implicated, ibuprofen, nabumetone, naproxen, and tolmetin were found to be associated.

CONCLUSIONS

Nephrotic syndrome due to membranous nephropathy should be recognized as an idiosyncratic drug reaction to many NSAIDS. Because withdrawal of the drug may result in prompt and complete recovery of normal renal function, a history of NSAID intake should be sought in patients with membranous nephropathy.

Ketorolac-induced acute renal failure in a previously healthy adolescent

Ketorolac has become an important component of analgesic regimens for children as well as adults because of its lack of adverse effects on respiratory, cardiovascular, and neurologic function. Although initially used parenterally in hospitalized patients, the development of an oral ketorolac dose form extended its use to the outpatient setting, where its potency has been considered an advantage over traditional therapies.1-3

Several cases of hyperkalemia and oliguric acute renal failure associated with ketorolac use have been reported in the medical literature.4-12 Elderly hospitalized patients receiving large doses of ketorolac intramuscularly (IM) after major surgery seem to be at greatest risk.

Corneal sensitivity and burning sensation. Comparing topical ketorolac and diclofenac

OBJECTIVES

To compare the effect of topical 0.5% ketorolac tromethamine and 0.1% diclofenac sodium on human corneal sensitivity and to assess the intensity of burning sensation at specific intervals after drop instillation.

DESIGN AND SETTING

Double-masked parallel clinical study.

PATIENTS

Eleven women and 4 men (8 white, 4 Hispanic, 3 Asian), 22 to 60 years of age (mean [ +/- SD], 34 +/- 10 years).

INTERVENTIONS

Repeated instillation of either ketorolac and placebo or diclofenac and placebo at 5-minute intervals.

MAIN OUTCOME MEASURES

Assessment of corneal sensitivity before instillation, immediately after instillation, and after termination of drop application; and subjective evaluation of burning sensation by asking participants to rate burning on a scale ranging from 0 (none) to 3 (severe) after each drop application.

RESULTS

Both diclofenac (P < .01) and ketorolac (P < .01) decreased corneal sensitivity significantly, while the placebo had no measurable effect. After administration of additional drops over time, the effect of diclofenac and ketorolac increased. After termination of the drug instillation, corneal sensitivity returned to baseline significantly slower (P < .01) in participants receiving diclofenac than in those receiving ketorolac. Ketorolac (P = .01) and diclofenac (P < .05) were significantly more effective in whites than in nonwhites. Mean burning sensation was mild, and there was no statistically significant difference between the 2 drugs on this measure (P = .12).

CONCLUSIONS

The decrease in corneal sensitivity in normal human corneas is more pronounced and longer lasting with diclofenac than with ketorolac. Both drugs are well tolerated topically and may be useful for pain reduction after refractive corneal surgery.

Safety of intravenous ketorolac therapy in children and cost savings with a unit dosing system

OBJECTIVE

To determine the incidence of side effects with the short-term use of intravenously administered ketorolac in children and the overall cost savings with a unit dosing system.

STUDY DESIGN

We prospectively examined the incidence of complications arising from the intravenous administration of ketorolac to 1747 children (14,810 doses) during a 3-year, 3-month period and assessed cost savings resulting from dividing 60 mg syringes into 7.5, 15, 30, and 60 mg unit doses. Complications were recorded prospectively into a computerized database. Estimated drug costs to the pharmacy were calculated on the basis of the total numbers of each drug fraction administered, with allowance for 1O% wastage as a result of drug expiration.

RESULTS

Side effects occurring with ketorolac administration were rare. Four patients (0.2%) had hypersensitivity reactions to the drug, two of them possibly on the basis of latex allergy. Two patients (O.1%) had renal complications but were subsequently found to have underlying causes that could account for their renal symptoms. One patient (0.05%) had massive gastrointestinal bleeding in the postoperative period. With fractionation of 60 mg syringes, total drug cost to the pharmacy was $34,786, rather than the $86,639 that would have been spent had a single syringe been used for each dose.

CONCLUSION

Ketorolac proved safe for short-term intravenous use in children more than 1 year of age when patients with known contraindications to the use of non-steroidal antiinflammatory drugs were excluded. A considerable reduction in drug costs can be achieved with fractionation of premixed syringes into unit doses.

Single-dose intramuscular ketorolac versus diclofenac for pain management in renal colic

A double-blind controlled study was designed to compare the effective- ness of a single intramuscular dose of 60 mg ketorolac with that of 75 mg diclofenac in the treatment of renal colic and to monitor side effects. Fifty-seven patients completed the study, 27 in the ketorolac group and 30 in the diclofenac group. Effectiveness of treatment was monitored by pain relief reported on a 4-point verbal scale at different time points. At 60 minutes 77.8% and 86.6% (P = 0.4) of patients, and at 120 minutes 81.5% and 96.6% (P = .1 5) of patients, reported significant pain relief following ketorolac and diclofenac doses, respectively. Both groups had an equal 92% significant pain relief at discharge from the emergency department. Both drugs were well tolerated by the patients. Ketorolac therefore, seems as effective as diclofenac in the treatment of renal colic.

A comparison of the effect of intramuscular diclofenac, ketorolac or piroxicam on post-operative pain following laparoscopy

Sixty patients presenting for in-patient gynaecological laparoscopic surgery were randomly allocated to receive either diclofenac 75 mg (n = 20), ketorolac 30 mg (n = 20) or piroxicam 20 mg (n = 20) as an intramuscular (i.m.) injection immediately after induction of anaesthesia. Post-operative Visual Analogue Scores at rest, over the first 24 h after surgery, using a 10 cm scale, ranged from 3.2-0.5 in the diclofenac group, 2.7-0.85 in the ketorolac group and 2.8-0.5 in the piroxicam group. The scores did not differ significantly between the three groups (P > 0.05). Mean time (SD) to first analgesia was 27 (94) min in the piroxicam group, 16 (30) min in the diclofenac group and 62 (120) min in the piroxicam group. Six out of 20 patients in the diclofenac group required further analgesia compared with nine out of 20 in the other two drug groups, this was not significant. There were no reports of increased bleeding, bronchoconstriction, bleeding from the upper gastrointestinal tract, renal impairment or pain from the intramuscular (i.m.) injection site in any of the groups. The administration of a non-steroidal anti-inflammatory drug to patients presenting for laparoscopic surgery reduces post-operative pain and analgesic requirements, and piroxicam 20 mg provides a suitable alternative to 75 mg diclofenac and 20 mg ketorolac.

Asthma caused by topical application of ketorolac

BACKGROUND

Ketorolac tromethamine 0.5 percent ophthalmic solution is a widely used nonsteroidal anti-inflammatory drug (NSAID) in ophthalmology. Ketorolac eye drops have not been implicated previously as a cause of NSAID-induced asthma.

STUDY DESIGN

A patient with severe asthma after topical application of ketorolac is described. The current ophthalmic indications for topical application of ketorolac and reported hypersensitivity reactions with systemic use of ketorolac are reviewed.

RESULTS

A 44-year-old woman with chronic asthma, rhinosinusitis, and nasal polyps inadvertently was given ketorolac to be applied topically. After applying the first dose of ketorolac, an exacerbation of her asthma developed, necessitating hospital admission.

CONCLUSIONS

Topical application of ketorolac is safe in the vast majority of ophthalmology patients. However, NSAID eye drops should not be prescribed for patients with aspirin or NSAID allergy or the combination of asthma and nasal polyps unless the patient is known to tolerate aspirin without trouble.

Preoperative ketorolac increases bleeding after tonsillectomy in children

PURPOSE

To compare the incidence of vomiting following codeine or ketorolac for tonsillectomy in children.

METHODS

We had planned to enrol 240 patients, aged 2-12 yr undergoing elective tonsillectomy into a randomized, single-blind study in University Children's Hospital. The study was terminated, after 64 patients because interim analysis of the data by a blinded non-study scientist concluded that the patients were at undue risk of excessive perioperative bleeding. After induction of anaesthesia by inhalation with N2O/halothane or with propofol 2.5-3.5 mg.kg-1 i.v., the children were administered 150 micrograms.kg-1 ondansetron and 50 micrograms.kg-1 midazolam. Maintenance of anaesthesia was with N2O and halothane in O2. Subjects were administered either 1.5 mg.kg-1 codeine im or 1 mg.kg-1 ketorolac i.v. before the commencement of surgery. Intraoperative blood loss was measured with a Baxter Medi-Vac Universal Critical Measurement Unit. Postoperative management of vomiting and pain was standardized. Vomiting was recorded for 24 hr after anaesthesia. Data were compared with ANOVA, Chi-Square analysis and Fisher Exact Test.

RESULTS

Thirty-five subjects received ketorolac. Demographic data were similar. The incidence of vomiting during the postoperative period was 31% in the codeine-group and 40% in the ketorolac-group. Intraoperative blood losses was 1.3 +/- 0.8 ml.kg-1 after codeine and 2.2 +/- 1.9 ml.kg-1 after ketorolac (mean +/- SD) P < 0.05. Five ketorolac-treated patients had bleeding which led to unscheduled admission to hospital, P < 0.05, Exact Test.

CONCLUSION

Preoperative ketorolac increases perioperative bleeding among children undergoing tonsillectomy without beneficial effects.

Interaction of low molecular weight heparin with ketorolac

Postoperative patients may receive ketorolac, a nonsteroidal antiinflammatory drug that inhibits platelet function, for analgesia and may receive low-molecular-weight heparin (LMWH) for thrombosis prevention. We investigated whether the combination of these two agents increases blood loss in a rabbit model of hemostasis. In a randomized, blinded study, animals received either intramuscular ketorolac (0.5 mg/kg or 1.0 mg/kg) and subcutaneous saline solution, subcutaneous LMWH (100 U/kg) and intramuscular saline solution, ketorolac (0.5 mg/kg or 1.0 mg/kg) and subcutaneous LMWH (100 U/kg), or intramuscular and subcutaneous saline solution given 30 minutes before ear incision and measurement of blood loss. Collagen-induced platelet aggregation was examined and anti-Xa levels were determined by using a chromogenic substrate method. As compared with results in saline-treated controls, blood loss was significantly increased in animals receiving ketorolac in a dose of 1.0 mg/kg but not in those treated with 0.5 mg/kg. The addition of LMWH did not further increase blood loss above that observed with either dose of ketorolac alone. Platelet aggregation was inhibited by both doses of ketorolac. The anti-Xa levels in the LMWH-treated animals were comparable to those measured in patients receiving these agents for prophylaxis (0.09 to 0.13 U/ml). We conclude that in the rabbit model, LMWH does not augment ketorolac-associated bleeding when both agents are used in doses comparable to those given to human patients.

Intravenous ketorolac tromethamine worsens platelet function during knee arthroscopy under spinal anesthesia

Ketorolac prolongs bleeding time and inhibits platelet aggregation and platelet thromboxane production in healthy, awake volunteers. However, platelet function was recently shown not to worsen after ketorolac was given during general anesthesia. The purpose of this study was to investigate platelet function changes during a standardized spinal anesthetic and surgery, as well as after a single intraoperative dose of intravenous (IV) ketorolac. The study comprised 30 ASA physical status I patients undergoing spinal anesthesia for knee arthroscopy. Subjects were randomized to receive either ketorolac 60 mg IV 15 min after skin incision or placebo IV. Platelet function testing consisted of an Ivy bleeding time, platelet aggregometry with adenosine diphosphate (ADP) and collagen, thromboelastography (TEG), and serum thromboxane B2 (TxB2) assays. Platelet function testing was performed: 1) 15 min prior to the performance of spinal anesthesia; 2) 10 min after surgical skin incision; and 3) 45 min after administration of study drug. The placebo group demonstrated no changes in any platelet function variable during spinal anesthesia and surgery relative to preoperative values. The ketorolac group, however, demonstrated a significant increase in bleeding time from postincision to poststudy drug data points (213 +/- 60s to 275 +/- 85s, mean +/- SD; P < 0.01). Further, platelet aggregometry to collagen was diminished in the ketorolac group from preoperative to poststudy drug data points (90.8% +/- 7.6% to 60.5% +/- 32.5%; P < 0.01). Platelet aggregometry with ADP, however, was unchanged in the ketorolac group. Platelet TxB2 production decreased dramatically in the ketorolac group from preoperative to poststudy drug data points (157.2 +/- 129.4 to 0.3 +/- 0.3 ng/mL; P < 0.01). Platelet function does not appear to be accentuated during spinal anesthesia as it is during general anesthesia. Unlike during general anesthesia, platelet function during spinal anesthesia is impaired, with respect to bleeding time and platelet aggregometry to collagen, by a single intraoperative dose of IV ketorolac.

Renal papillary necrosis following emergency department treatment of migraine

New medications have lessened the need for narcotic medications in the acute treatment of migraine. Some of these new medications include parenteral dihydroergotamine (DHE), sumatriptan, and ketorolac. Treatment failures still occur, though, and some cases necessitate adding a second agent to one that has been ineffective. We report a case of a 46-year-old man who suffered renal papillary necrosis 12 days after receiving parenteral DHE, sumatriptan, and ketorolac for treatment of a severe migraine headache. There were no signs of an adverse drug reaction at the time of his emergency department visit. The case illustrates a potential hazard of this combination in the acute treatment of migraine.

A comparison of the efficacy of ketorolac and indomethacin for postoperative analgesia following laparoscopic surgery in day patients

The analgesia provided in the postoperative period by three regimens commonly used in our private anaesthetic practice were compared in a double-blind study of one hundred and thirty-seven women presenting for day-case laparoscopic procedures. After random allocation into three groups, all patients were similarly anaesthetized and then received both a rectal suppository and an IM injection. Group P received two placebos, Group I had an indomethacin suppository 100 mg and Group K an IM injection of ketorolac 30 mg. The trial showed a statistically significant reduction in pain at 180 minutes postoperatively in the group receiving ketorolac (visual analog pain score of 13.8 v 21.7). The parenterally administered ketorolac may be a useful analgesic supplement in these patients. However the trial was aborted following the appearance in the literature of case reports of postoperative renal failure. Further investigation of the efficacy and side-effect profile of reduced doses may be warranted.

Does patient-controlled analgesia achieve better control of pain and fewer adverse effects than intramuscular analgesia? A prospective randomized trial

OBJECTIVE

To compare three analgesic regimens in patients undergoing colon resection: patient-controlled morphine sulfate analgesia (PCA), intramuscular (IM) morphine, and IM ketorolac tromethamine.

DESIGN

Prospective randomized case series.

SETTING

Rural, private teaching hospital.

PATIENTS

All patients (307) scheduled to undergo a major colon resection between January 1, 1992, and December 31, 1993, were eligible to participate. Of these, 10 (3%) were missed in the screening process, 132 (43%) declined participation, 73 (24%) were excluded, and 92 (30%) were enrolled and randomly assigned to a treatment group.

INTERVENTIONS

Ninety-two patients were enrolled in the study. Two patients never received the medication to which they were assigned, owing to administrative error; their data was not analyzed. Of the remaining patients, 31 were randomized to the PCA morphine group, 31 were randomized to the IM morphine group, and 28 were randomized to the IM ketorolac group. The randomly assigned drug was first administered in the post-anesthesia care unit. On arrival on the postoperative ward, the patient was asked to rate his or her pain using both a numerical rating scale and a visual analog scale at 30 minutes; 1, 2, 3, 4, and 6 hours after arrival on the ward; and every 4 hours throughout the first 5 postoperative days. The Mini-Mental State Examination (MMSE) was administered the day before surgery and then daily for the first 5 postoperative days. The first day the patient passed flatus after surgery was also recorded.

MAIN OUTCOME MEASURES

The end points analyzed were adverse effects, duration of postoperative ileus, degree of pain control, length of hospitalization, and development of postoperative confusion as measured on serial MMSEs.

RESULTS

Only two patients, both in the PCA group, reported adverse effects; neither required a change in analgesia group. Significantly more patients assigned to IM ketorolac broke protocol and required alternative analgesia than did patients in the morphine groups (32% ketorolac vs 16% IM morphine and 0% PCA). The ketorolac group had a significantly shorter duration of ileus than either morphine group (P<.0l). The ketorolac group also had significantly lower pain scores (P<.04) and less postoperative confusion than the morphine groups (P<.03), although these results are limited by missing values. The ketorolac group had a significantly shorter length of stay than either morphine group (P<.01), while there was no significant difference between the morphine groups (P=.75).

CONCLUSIONS

While it appears that ketorolac provides a better postoperative course than either IM or PCA morphine in terms of pain control, postoperative confusion, length of stay, and duration of ileus, 18% of our patients assigned to ketorolac required additional analgesia, and there was a strong patient preference for PCA. Most patients should probably be managed with PCA narcotics, but the addition of ketorolac might reduce narcotic dose and resultant adverse effects. Those patients particularly prone to adverse effects should receive primarily ketorolac.

Colonic ulceration associated with the systemic use of nonsteroidal antiinflammatory medication

We report the first case of colonic ulceration precipitated by the intramuscular administration of ketorolac. This report suggests a role for the systemic effects of nonsteroidal antiinflammatory agents in the development of gastrointestinal ulceration.