Evaluation of the financial impact of ketorolac tromethamine therapy in hospitalized patients

This retrospective cohort study aimed to determine the resource utilization and cost consequences of ketorolac tromethamine in postoperative pain management in a variety of clinical circumstances. All patients were treated at LDS Hospital, Salt Lake City, Utah, a 520-bed teaching hospital. A long-term archive of clinical and financial data from a computerized hospital information system was searched for patients with specified primary International Classification of Diseases, 9th Revision, Clinical Modification discharge diagnoses treated from June 1, 1990, to July 1, 1992, who received ketorolac (n = 229). These patients were matched with cohort patients (n = 821) treated from July 1, 1989, to May 31, 1990, who did not receive ketorolac. The archive contained information on ketorolac exposure as well as concurrent drug therapy and adverse drug events that had been prospectively evaluated during hospitalization throughout the study and cohort periods. Detailed costs were available for each patient. The study examined attributable differences in lengths of stay and total costs using linear regression modeling. We found a statistically significant attributable decreased length of stay for ketorolac patients of 1.15 days. Case patients also had reduced usage of narcotic drugs (4.39 fewer doses than cohorts and 15.6 hours shorter duration of narcotics than cohorts), reduced use of antiemetic and antipruritic medications, and reduced numbers of adverse events. Linear regression modeling showed that ketorolac use was significantly related to reduced cost using inflation-adjusted dollars. We believe that ketorolac has significant cost advantages over opiate analgesics because of its narcotic-sparing effects. Advantages of ketorolac use include reduced rates of adverse drug events, reduced lengths of stay, especially for orthopedic surgery, and reduced overall hospital costs for diagnosis-related groups associated with cholecystectomy.

Efficacy of ketorolac in the management of pain associated with root canal treatment

Patients requiring root canal treatment were randomly assigned to one of three groups. The first group received Ketorolac oral 10 mg at six hour intervals for 24 hours, the second group received Ketorolac (Toradol) injectable 10 mg at the height/depth of the buccal vestibule of the tooth to be treated, and the third group received no assigned medication. Significantly better pain relief was achieved when Ketorolac injectable or oral was used then when no drug was administered. Some of the patients in the Ketorolac injectable group felt that an additional dose of medication would have been helpful at the six- to eight-hour postoperative period. However, there was no significant difference in pain relief between the two groups treated with different drug regimens.

Randomized double-blind comparison of the analgesic efficacy of intramuscular ketorolac and oral indomethacin in the treatment of acute gouty arthritis

STUDY OBJECTIVE

To compare the analgesic effect of IM ketorolac tromethamine with that of oral indomethacin in the treatment of acute gouty arthritis.

DESIGN

Prospective, randomized, double-blind, controlled, parallel group clinical trial.

SETTING

Two urban emergency departments.

PARTICIPANTS

Twenty consecutive patients who presented to the ED with acute gout.

INTERVENTIONS

Each patient was randomly assigned to receive in the ED (1) 60 mg of IM ketorolac and oral placebo or (2) 50 mg of oral indomethacin and IM placebo. The patients rated the intensity of their pain on a Wong-Baker pain scale (which runs from 0 to 5) before treatment and 30, 60, 90, and 120 minutes after treatment. All the patients were discharged with instructions to take oral indomethacin and to complete pain score cards at home at 6, 12, and 24 hours.

RESULTS

The 10 patients in each group were similar with regard to age, sex, race, and initial mean pain score. After 2 hours, the mean pain scores (+/- SD) for the ketorolac group had decreased from 4.5 +/- .71 to 1.4 +/- 1.43 (P < .05), and the mean score for the indomethacin group had decreased from 4.4 +/- .70 to 1.5 +/- 1.18 (P < .05). The difference between the two groups was not significant. At 6 hours, there was some pain rebound in the ketorolac group.

CONCLUSION

IM ketorolac and oral indomethacin are similar in the relief of the pain of acute gouty arthritis in the ED.

Nonopioid analgesics shorten the duration of postoperative ileus

Morphine inhibits propagating and stimulates nonpropagating colon contractions in monkeys and humans. The use of morphine or other opioids that inhibit propulsive contractions prolongs postoperative ileus. In contrast, ketorolac tromethamine, a nonsteroidal analgesic, has no effect on colon contractions in monkeys. In 14 patients having elective abdominal operations, bipolar electrodes were implanted on the right (n = 13) and left (n = 10) colon. Group A (n = 8) received ketorolac, 30 mg IM q6h, for pain relief. Group B (n = 6) needed supplemental morphine, 2-10 mg IV or IM, plus ketorolac to control their pain. Myoelectric activity was recorded from each subject on postop Days 1-5 and analyzed by computer for electrical control activity (ECA), short and long electrical response activity (ERA), and propagation of long ERA. There was a difference between the two groups in return of propagated long ERA bursts that correlated with clinical recovery from postoperative ileus. Postoperative analgesia with ketorolac resulted in faster resolution of ileus compared to morphine plus ketorolac because opioid-induced motor abnormalities in the colon were avoided.

Anterior cruciate ligament reconstruction as an outpatient procedure

During a 27-month period, 222 patients with 227 anterior cruciate ligament-deficient knees underwent arthroscopically assisted reconstructions as outpatient procedures. Bone-tendon-bone autografts were used for 169 of these reconstructions; the other 58 were done with bone-tendon-bone allografts. Additional procedures were performed on 180 of the patients. The interval from injury to reconstruction averaged 29 months. The protocol developed at our clinic employs a general anesthetic administered with the intent of same-day discharge, infiltration of the skin and joint with bupivacaine, a cold compressive dressing, and the use of both ketorolac tromethamine and a Schedule III narcotic (acetaminophen with codeine or with propoxyphene) for postoperative pain control. At an average followup of 10 months, no readmissions in the immediate postoperative period had been required and no short- or long-term postoperative complications could be attributed to the protocol. This safe and effective technique offers the patient the advantage of anterior cruciate ligament reconstruction as a same-day procedure and allows the surgeon to implement its use in any outpatient setting without additional discharge planning.

Approaches for improving the stability of ketorolac in powder blends

Methods for improving the stability of ketorolac powder blends under elevated humidity and temperature conditions were investigated. The approaches that were examined for potentially increasing the stability of ketorolac were varying the ketorolac salt form, altering the excipient ratios, and adding antioxidants or pH modifiers to the formulation. The ketorolac powder blends were stored for 3 months at 75% relative humidity (RH) and 40, 50, and 60 degrees C. The results showed that the salt form of ketorolac had a large impact on stability after 3 months of storage at 50 degrees C/75% RH. The calcium salt powder blend and the free acid powder blend exhibited only 0.2% and 0.5% drug loss, respectively, whereas the tromethamine salt powder blend showed a 10.2% drug loss. Varying the ratios of lactose, microcrystalline cellulose, and croscarmellose sodium in the powder blends of ketorolac tromethamine showed that croscarmellose sodium and microcrystalline cellulose destabilized ketorolac. Addition of propyl gallate (1% w:w) to ketorolac tromethamine powder blends increased the stability of the ketorolac significantly. Addition of pH modifiers caused a modest improvement in the stability of ketorolac.

Transdermal delivery of ketorolac tromethamine: permeation enhancement, device design, and pharmacokinetics in healthy humans

Transdermal delivery of ketorolac tromethamine, a potent non-narcotic analgesic, through human skin in vitro and in vivo was investigated. In order to enhance and sustain the flux of ketorolac through human skin, various compositions of isopropyl alcohol (IPA), water, and isopropyl myristate (IPM) were evaluated. The solubility of ketorolac acid in an IPA/water binary vehicle mixture increased as the volume fraction of IPA increased from 0 to 90%. The solubility of ketorolac acid in an IPA/water/IPM (saturated) ternary vehicle mixture was practically the same as in the IPA/water binary vehicle mixture. The permeation of ketorolac acid through cadaver skin was evaluated using modified Franz diffusion cells. The skin flux increased as the IPA volume fraction was increased from 0 to 50% and then leveled off beyond 80% IPA loading. When IPM was added to the IPA/water binary vehicle mixture, a significant increase in the skin flux of ketorolac was observed. The skin flux decreased exponentially as the donor solution pH was raised from 3.5 to 7.0. The permeability of ketorolac through various membranes such as a microporous membrane and pressure-sensitive adhesive was evaluated. While a microporous membrane offered practically no diffusion resistance, the in vitro flux of ketorolac through cadaver skin decreased substantially upon lamination of pressure-sensitive adhesive onto a microporous membrane. Three liquid-reservoir type transdermal devices were fabricated using 6.5% ketorolac tromethamine gel, a microporous membrane, an adhesive membrane, and polyester backing film: TD-A (microporous membrane/acrylic adhesive), TD-B (microporous membrane/silicone adhesive), and TD-C (microporous membrane). The pharmacokinetics of ketorolac in 10 healthy humans following application of a transdermal device for 24 h was evaluated. The maximum plasma concentrations (Cmax) were 0.20, 0.18, and 0.82 microgram/mL for TD-A, TD-B, and TD-C, respectively. The total AUC values for the concentration-time curves were TD-C > TD-A > TD-B, and the terminal half-life ranged from 6.6 to 9.7 h.

Pharmacokinetics of oral ketorolac in the rat

The pharmacokinetics of ketorolac, a potent analgesic agent used for relief of moderate to severe pain, has been studied in rats who received oral doses of 1, 3.2 or 5.6 mg/kg of ketorolac tromethamine. Blood samples were obtained at selected times during 24 h after medication, and ketorolac concentrations were determined by high performance liquid chromatography. After administration of ketorolac, blood concentrations increased rapidly reaching a dose-dependent maximal concentration in about 20 min. Then, concentrations decayed with a half-life of about 6 h. A linear increase in Cmax and AUC as a function of the dose was observed, and not statistically significant difference was observed in AUC/dose or Cmax/dose between doses, indicating that pharmacokinetics of ketorolac is linear in the range of doses studied.

Racemization of ketorolac in aqueous solution

The racemization of ketorolac was studied in aqueous buffered solution at 25 and 80 degrees C and analyzed in detail with respect to the catalytic species in solution. The reaction has a U shaped pH rate profile at 80 degrees C with the pH of maximum stability occurring in the region of pH 3.0-7.5. A T90 value of 8 months was observed for a 1.5% (R)-ketorolac tromethamine solution at pH 7.4 and 25 degrees C. Additionally, the data shows that alternative salt forms are necessary in order to prepare a stable single isomer formulation. Alternative buffers, in particular phosphate buffer, provide formulations exhibiting a T90 greater than 2 years.

Ketorolac for early postoperative analgesia

STUDY OBJECTIVE

To determine the efficacy and speed of onset of analgesia of a single dose of intravenous (IV) or intramuscular (IM) ketorolac tromethamine following major orthopedic surgery.

STUDY DESIGN

Double-blind, randomized, placebo-controlled trial.

SETTING

A district general hospital in England.

PATIENTS

112 patients aged 18 to 80 years suffering moderate or severe pain following orthopedic surgery.

INTERVENTIONS

Patients were randomized to receive 30 mg ketorolac IV, 30 mg ketorolac IM, or placebo following surgery.

MEASUREMENTS AND MAIN RESULTS

Verbal pain intensity scores were performed prior to admission to the study, then frequently for the first 45 minutes following administration of study medication, and subsequently at hourly intervals. Times to request for further analgesia were noted. Patient assessment of overall acceptability and pain relief of the study medication was recorded. There was no statistical difference in speed of onset of analgesia between the ketorolac groups and placebo. Median (range) times to first analgesic following study drugs were: ketorolac IV 45 minutes (9 to 1440 minutes), ketorolac IM 34 minutes (10 to 1440 minutes), placebo 24 minutes (10 to 615 minutes). There was a statistically significant difference between the ketorolac groups and placebo (ketorolac IV vs. placebo, p < 0.01; ketorolac IM vs. placebo, p = 0.03). Patient assessment of overall acceptability and pain relief was significantly better for IV ketorolac compared with placebo (p < 0.01). By 6 hours, 78% of the IV ketorolac group and 95% of the IM ketorolac and placebo groups required further analgesia.

CONCLUSIONS

Despite high patient acceptability compared with placebo, the use of ketorolac as the sole analgesic failed to control postoperative pain following major orthopedic surgery. IV administration of ketorolac conferred no advantages over the IM route with regard to efficacy or speed of onset.

Results of a survey of patients with ocular allergy treated with topical ketorolac tromethamine

Exposure of the eye to airborne particles in patients predisposed to allergy often results in the signs and symptoms of allergic conjunctivitis such as red, itchy eyes and ocular discharge. The mediators of these allergic symptoms include histamine, inflammatory substances such as prostaglandins, and other products of arachidonic acid metabolism (ie, leukotrienes). Ketorolac tromethamine is a nonsteroidal anti-inflammatory agent that inhibits the activity of cyclooxygenase, one of the two major enzymes responsible for the conversion of arachidonic acid to inflammatory substances. A multicenter patient survey was performed to evaluate the effectiveness of topical ketorolac tromethamine in treating the symptoms of allergic conjunctivitis. After ocular administration of ketorolac tromethamine, 90% (246/272) of patients reported that their eyes felt better. Eighty-four percent (173/206) of respondents rated ketorolac tromethamine as good to excellent in relieving their overall symptoms of ocular allergy, and 86% (217/251) of patients found the study drug produced good to excellent relief of their ocular itching usually within minutes to 1 hour of administration. Results of this survey found ketorolac tromethamine is effective in relieving ocular itching, the hallmark symptom of allergic conjunctivitis. In addition, these results provide further evidence that the products of arachidonic acid metabolism contribute to the symptoms of allergic conjunctivitis.

Opioid and nonopioid analgesic drug effects on colon contractions in monkeys

Opioid drugs administered postoperatively for pain relief cause increased frequency of nonpropulsive phasic contractions but decreased to absent propulsive migrating contractions in the colon, thus importantly influencing the duration of postoperative ileus. Ketorolac is thought to permit earlier return of bowel function postoperatively compared to morphine. Four monkeys had sets of three strain gauge force transducers implanted on the right and left colon at laparotomy. After recovery, animals were fasted overnight and had colon contractions recorded. After a 1-hr baseline period, 200 micrograms/kg morphine sulfate or 1 mg/kg ketorolac tromethamine was injected intramuscularly and recording continued. Each animal received four injections of each drug. Records were analyzed visually for frequency of phasic on migrating contractions. There was no difference in the frequency of phasic or migrating contractions after injection of ketorolac. Morphine, as expected, increased the frequency of phasic and decreased the frequency of migrating contractions in the colon. Ketorolac does not affect the frequency of colon contractions.

Gastrointestinal complications associated with intramuscular ketorolac tromethamine therapy in the elderly

OBJECTIVE

To report 3 cases of gastrointestinal (GI) complications associated with the use of intramuscular ketorolac tromethamine therapy in elderly patients.

CASE SUMMARIES

In case 1, an 88-year-old woman was taken to surgery for the management of an acute abdomen and repair of a 2+ cm perforated prepyloric gastric ulcer. The patient had received a total 16 doses of ketorolac 30 mg im. The patient died after surgery from complications associated with bacterial and candidal sepsis, as well as acute renal failure. In case 2, an 80-year-old woman with no known history of GI problems developed a prepyloric gastric ulcer, which perforated and penetrated into the pancreas after the patient received 13 doses of ketorolac 30 mg im. The patient died from complications associated with candidal sepsis, peritonitis, and cardiopulmonary collapse. In case 3, an 85-year-old man with a history of a gastric ulcer developed GI bleeding after receiving a total of 9 doses of ketorolac 30 mg im. The bleeding was stabilized and the patient was discharged 12 days later in stable condition.

DISCUSSION

Ketorolac tromethamine is a nonsteroidal anti-inflammatory drug with potent analgesic properties. We report 3 cases of GI complications associated with intramuscular ketorolac therapy in the elderly. A temporal relationship was established with the development of gastric ulceration in 2 patients and the recurrence of a gastric ulcer in the third patient.

CONCLUSIONS

We recommend that the manufacturer's guidelines be followed when ketorolac is used in elderly patients, and the drug should not be used in patients with a history of gastric ulcer disease. The use of misoprostol may be warranted as prophylactic therapy in high-risk patients who are receiving ketorolac.

Effect of ketorolac tromethamine on bleeding and on requirements for analgesia after total knee arthroplasty

The effect of ketorolac tromethamine, a non-steroidal anti-inflammatory drug, on postoperative blood loss and on the requirement for morphine was assessed after total knee arthroplasty, an operation in which blood loss is mainly measured rather than estimated. The purpose of this prospective, randomized, double-blind clinical trial was to determine whether administration of ketorolac in the perioperative period would increase bleeding related to the operation. Fifty-nine patients who had a total knee arthroplasty received either thirty milligrams of ketorolac or a placebo consisting of saline solution, intravenously, every six hours, in four doses. The first dose was administered about an hour before the end of the operation. Blood loss and use of morphine for pain control were measured for the first twenty-four hours postoperatively. The per cent change in the hematocrit and the amount of transfused blood were also recorded. The patients who received ketorolac used 27 per cent less morphine than those who received the placebo (40.0 +/- 23.4 milligrams compared with 55.1 +/- 23.5 milligrams [mean and standard deviation]); this difference was significant (p < 0.05). On the first day after the operation, the hematocrit decreased from 0.364 +/- 0.043 preoperatively to 0.278 +/- 0.032 in the patients who received ketorolac and from 0.363 +/- 0.046 to 0.298 +/- 0.030 in the patients who received the placebo. The 6 per cent greater decrease in the group that received ketorolac was significant (p < 0.05) but not clinically important.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute sensorineural hearing loss following intravenous ketoralac administration

Ketoralac is an injectable nonsteroidal antiinflammatory drug (NSAID) widely used in both out-patient and in-patient settings. Side effects such as acute renal failure, hyperkalemia, gastritis, gastrointestinal bleeding, and asthmatic exacerbation, although rare, have been previously reported. We report the case of a 20-year-old female with polyarteritis nodosa (PAN) who developed bilateral sensorineural hearing loss 25 minutes after receiving 30 mg of intravenous ketoralac. The patient denied any previous medication sensitivities, and was taking oral methotrexate and prednisone at the time of emergency department admission. Both PAN and methotrexate have been independently demonstrated to cause sensorineural hearing loss. We postulate that the patient's hearing loss was the result of ketoralac's direct and indirect ototoxic effects that were potentiated as a result of her underlying illness and medications. We recommend the cautious use of ketorolac in patients with underlying illnesses where NSAID-induced ototoxicity could result in adverse otologic consequences.

A pilot project in office-based diagnostic esophagogastroduodenoscopy comparing two nonintravenous methods of sedation and anesthesia

OBJECTIVE

To evaluate the performance and findings of diagnostic esophagogastroduodenoscopy (EGD) procedures in a primary care office setting, comparing two nonintravenous methods of sedation and anesthesia.

DESIGN

A consecutive case series of patients with appropriate indications referred over a 13-month period for the EGD procedure was studied. Procedure outcomes and patient acceptance were evaluated following the procedure.

SETTING

Patients were referred from community primary care physician offices to another community private office.

PATIENTS

Medically stable adult patients with indications for nonemergent EGD were referred for evaluation.

INTERVENTION

Esophagogastroduodenoscopy was performed in an office setting using small-caliber (7.9-mm or 9.0-mm) fiberoptic endoscopes. Patients were given either diazepam orally and ketorolac tromethamine intramuscularly or triazolam orally and butorphanol tartrate spray intranasally as sedation prior to the procedure.

MAIN OUTCOME MEASURES

Clinical findings observed, histopathologic results, complications, oxygen desaturation, cardiac dysrhythmias, and length of procedures were recorded. Patients reported pain and satisfaction scores on a linear numeric scale following the procedure.

RESULTS

No major complications were noted in this study population. Seventy-three percent (52/71) of all patients rated their discomfort during the office-based EGD procedure as mild, with 49% (35/71) giving the lowest possible pain score rating. Ninety-six percent (68/71) of all patients rated their satisfaction with the procedure as high, with 65% (46/71) reporting the highest possible level of satisfaction. The study did not demonstrate a significant difference in patient comfort or satisfaction between the two methods of nonintravenous sedation.

CONCLUSIONS

Two alternative methods to intravenous sedation and anesthesia appear to create adequate comfort and satisfaction for patients undergoing EGD and merit future study and consideration.

Intravenous ketorolac tromethamine does not worsen platelet function during knee arthroscopy under general anesthesia

Ketorolac (KT) prolongs bleeding time and inhibits platelet aggregation and platelet thromboxane production in healthy, awake volunteers. However, platelet function may be accentuated during the stress of general anesthesia (GA) and surgery. The purpose of this study was to investigate platelet function changes during a standard GA technique and surgery, as well as after a single intraoperative dose of intravenous (i.v.) KT. The study comprised 30 ASA physical status I patients undergoing GA for knee arthroscopy. Subjects were randomized to receive either KT 60 mg IV 15 min after skin incision or placebo i.v. Platelet function testing consisted of an Ivy bleeding time (BT), platelet aggregometry (PA) with adenosine diphosphate (ADP) and collagen, thromboelastography (TEG), and serum thromboxane B2 assays (TxB2). Platelet function testing was performed: 1) 15 min prior to the induction of GA, 2) 10 min after skin incision, and 3) 45 min after administration of study drug. BT decreased significantly in the placebo group from 263 +/- 133 s (mean +/- SD) preoperatively to 207 +/- 89 s postincision. BT did not change in the KT group. PA was unchanged after IV KT. TEG data was unchanged in both groups during anesthesia and surgery. TxB2 levels decreased markedly in the KT group from 106.9 +/- 96.2 ng/mL preoperatively to 0.4 +/- 1.2 ng/mL poststudy drug, P = 0.002. Platelet function appears to be accentuated during GA and surgery as evaluated by BT in the placebo group. Further, platelet function by BT, PA, and TEG was not inhibited after i.v. KT despite near complete abolition of TxB2 production.

Effects of lysine clonixinate and ketorolac tromethamine on prostanoid release from various rat organs incubated ex vivo

The release of prostanoids from rat brain, gastric mucosa, lungs and kidneys incubated ex vivo has been investigated for up to 5 h after oral administration of 10 mg/kg lysine clonixinate or 1 mg/kg ketorolac tromethamine. Additionally, 60 min after drug administration, a time point of near-maximal inhibition of prostanoid release, the effects of 2.5, 10 and 30 mg/kg lysine clonixinate and of 0.0225, 0.15 and 1 mg/kg ketorolac tromethamine were compared. In all organs investigated both drugs inhibited fatty acid cyclooxygenase (COX) in a dose-dependent manner, but ketorolac tromethamine was more potent and had a longer-lasting effect than lysine clonixinate. While the ID50 values for lysine clonixinate were in the same order of magnitude for all 4 organs investigated, ketorolac tromethamine exhibited some organ selectivity with a particularly high activity in the kidneys. This effect might be related to the renal toxicity of ketorolac tromethamine. On the other hand, the difference in potency was smallest in brain suggesting that inhibition of central prostanoid biosynthesis could contribute to the rapid and effective inhibition of pain by both drugs. IC50 values for inhibition of purified COX-1 and COX-2 in vitro were slightly lower for lysine clonixinate (2.4 and 24.6 micrograms/ml, respectively) than for ketorolac tromethamine (3.7 and 25.6 micrograms/ml, respectively).

Ketorolac (Toradol) and acute random-pattern skin flap survival in rat

OBJECTIVE

To assess the efficacy of sustained postoperative intramuscular ketorolac tromethamine (Toradol) at analgesic levels in the augmentation of acute, random-pattern skin flaps in rat.

DESIGN

Prospective, randomized, placebo-controlled, animal trial.

SETTING

Animal research laboratory, School of Medicine, Oregon Health Sciences University, Portland.

SUBJECTS

Forty-four adult male Sprague-Dawley rats (260 to 280 g).

INTERVENTIONS

Twenty-two treatment animals underwent modified McFarlane random-pattern skin flaps followed immediately by intramuscular loading doses of ketorolac. Treatment animals were then maintained on a regimen of intramuscular ketorolac using a three times a day dosing schedule for 14 days postoperatively. Twenty-two control animals underwent identical modified McFarlane random-pattern skin flaps and were given equivalent volumes of intramuscular saline on the same dosing schedule for the 14-day treatment period.

MAIN OUTCOME MEASURES

Postmortem measurements of skin flap ischemia (expressed as a percentage of total flap surface area) were performed for both treatment and control animals by three independent, non-blinded observers using the acetate tracing technique. Both pooled and individual data were statistically analyzed using personal computer software.

RESULTS

Forty-three of the 44 animals successfully completed the experimental trial. One animal in the treatment group died on postoperative day 3 of unknown causes. During the study period, one postoperative hematoma was detected in both the treatment and control groups. The mean percentage of skin flap ischemic necrosis observed in control animals (35.4%) was consistently less than that measured in the treatment group (36.4%). However, the difference in ischemic flap necrosis between control and treatment groups was not statistically significant (P = .6919).

CONCLUSIONS

Comparatively high-dose intramuscular ketorolac failed to augment acute, random-pattern skin flap survival in rat when initiated in the immediate postoperative period. Complications of prolonged, intramuscular ketorolac were not observed in this trial. Further studies using preoperative initiation of drug therapy may help to clarify the true efficacy of ketorolac in flap augmentation.

Perioperative ketorolac tromethamine and postoperative hemorrhage in cases of tonsillectomy and adenoidectomy

The charts of 258 patients undergoing tonsillectomy with or without adenoidectomy between June 1991 and June 1993 were reviewed. One hundred sixty-nine of these patients received ketorolac tromethamine during the perioperative period as a nonnarcotic alternative for postoperative pain management. The incidence of postoperative hemorrhage among patients who received ketorolac tromethamine was 10.1%, compared to 2.2% in those patients who received narcotic analgesia only. The average time to adequate oral intake and discharge was evaluated. Ketorolac appeared to moderately decrease the time to adequate oral intake. The use of ketorolac did not significantly alter the time to discharge. The increased incidence of postoperative hemorrhage in patients receiving ketorolac should be considered before this medication is used in the perioperative period. The risk/benefit ratio of ketorolac use as a postoperative analgesic may be better demonstrated in a prospective study.

Controlled evaluation of a bandage contact lens and a topical nonsteroidal anti-inflammatory drug in treating traumatic corneal abrasions

BACKGROUND

Treating traumatic corneal abrasions is a common problem for the ophthalmologist. Traditional management has been the use of a pressure patch. Three different therapeutic modalities were evaluated for their efficacy in treating traumatic corneal abrasions.

METHODS

Forty-seven consecutive patients with traumatic corneal abrasions were randomized prospectively in a single-masked, controlled clinical trial which compared the efficacy of (1) pressure patching, (2) a bandage contact lens, and (3) a bandage contact lens with a topical nonsteroidal anti-inflammatory drug (0.5% ketorolac tromethamine).

RESULTS

There was no significant difference in the healing time of the three groups. However, psychometric analysis showed a significant decrease in pain in the group that received a bandage contact lens with a topical nonsteroidal anti-inflammatory drug. There was a significant difference in the ability to return to normal activities in both contact lens groups compared with the pressure-patch group. There was no significant difference among the three groups with respect to photophobia, redness, ocular irritation, headache, or tearing.

CONCLUSION

Use of a bandage contact lens significantly shortens the time required for a patient to return to normal activities. Moreover, addition of a nonsteroidal anti-inflammatory drug to a treatment regimen significantly decreases the pain associated with traumatic corneal abrasions. Use of a bandage contact lens with a topical nonsteroidal anti-inflammatory may prove to be an effective adjunct in treating traumatic corneal abrasions.

Blockade of the antinociceptive activity of centrally administered ketorolac by nor-binaltorphimine

Antinociceptive activity of intracerebroventricularly administered ketorolac tromethamine was evaluated in mice by measuring inhibition of abdominal stretching induced by p-phenylquinone. Ketorolac tromethamine produced dose-dependent antinociception with an ED50 of 7.34 micrograms/mouse (4.97-10.82) and a maximal effect at 30 micrograms. Selective antagonists of opioid receptors were used to determine ketorolac's mechanism of action. The ketorolac tromethamine-induced antinociception was not blocked by the mu- and delta-opioid receptor antagonists, naloxone and ICI-174,864 (N,N-diallyl-Tyr-Aib-Aib-Phe-Leu), respectively; however, the kappa-opioid receptor antagonist nor-binaltorphimine dihydrochloride significantly blocked this effect. These findings suggest that activation of kappa-opioid receptors appears to play a role in the mechanism of the antinociceptive effect of ketorolac tromethamine. Ketorolac tromethamine may induce the release of endogenous kappa-opioids to produce central nervous system antinociception.

A comparison of topical ketorolac, systemic flurbiprofen, and placebo for the inhibition of bone loss in adult periodontitis

Systemic non-steroidal anti-inflammatory drugs (NSAIDs) have been shown to reduce alveolar bone loss in periodontitis. This study assesses the efficacy of a topical NSAID rinse, containing ketorolac tromethamine as the active agent. Adult periodontitis patients (n = 55) were studied in this 6-month randomized, double blind, parallel, placebo and positive-controlled study. Each patient had a least 3 sites at high risk for bone loss as assessed by low dose bone scan. Groups, balanced for gender, were assigned to one of three regimens: bid ketorolac rinse (0.1%) with placebo capsule; 50 mg bid flurbiprofen capsule (positive control) with placebo rinse; or bid placebo rinse and capsule. Prophylaxes were provided every 3 months. Monthly examinations assessed safety, gingival condition, and gingival crevicular fluid PGE2. Standardized radiographs were taken at baseline and at 3 and 6 months for digital subtraction radiography. A significant loss in bone height was observed during the study period in the placebo group (-0.63 +/- 0.11; P < 0.001), but not in the flurbiprofen (-0.10 +/- 0.12; P = 0.40) or ketorolac rinse (+0.20 +/- 0.11 mm; P = 0.07) groups. Nested ANOVA revealed that ketorolac and flurbiprofen groups had less bone loss (P < 0.01) and reduced gingival crevicular fluid PGE2 levels (P < 0.03) compared to placebo. ANOVA suggests (P = 0.06) that ketorolac rinse preserved more alveolar bone than systemic flurbiprofen at the dose regimens utilized. These data indicate that ketorolac rinse may be beneficial in the treatment of adult periodontitis.