Renal hemodynamic effects of chronic ketorolac tromethamine treatment in aged lean and obese Zucker rats

Ketorolac tromethamine is a relatively new non-steroidal anti-inflammatory drug (NSAID), with potent analgesic activity. Similar to other NSAIDs, ketorolac has the potential to impair renal function. To assess the renal hemodynamic impact of the ketorolac in aged lean and obese rats, ketorolac was orally administered to 46-week-old lean and obese Zucker rats for two weeks. Ketorolac was mixed with rat chow in a manner to provide a dose equivalent to 15 mg/kg body weight/day. Glomerular filtration rate (GFR) and effective renal plasma flow (ERPF) were measured under anesthesia by standard inulin and p-aminohippuric acid clearance method, respectively. Urinary prostaglandin (PG) E2 excretion was measured before and after ketorolac treatment. Ketorolac treatment significantly reduced obese rat GFR (0.47 +/- 0.08 vs 0.78 +/- 0.03 ml/min/g, p < 0.002) and ERPF (1.12 +/- 0.14 vs 2.36 +/- 0.26 ml/min/g, p < 0.001) relative to obese control rats. In comparison, ketorolac did not significantly alter lean rats GFR (0.77 +/- 0.04 vs 0.91 +/- 0.06 ml/min/g) or ERPF (1.92 +/- 0.20 vs 2.48 +/- 0.15 ml/min/g) relative to lean control rats. Chronic ketorolac treatment significantly reduced hematocrit by 20 and 30 percent in lean and obese rats relative to controls, respectively. The renal vascular resistance was significantly increased with ketorolac treatment in obese rats (36 +/- 4 vs 79 +/- 14 mmHg/ml/min, p < 0.001) but not lean rats (28 +/- 3 vs 38 +/- 5 mmHg/ml/min, NS) relative to corresponding controls.(ABSTRACT TRUNCATED AT 250 WORDS)

Analysis of ketorolac in postmortem blood

This paper describes analytical methods using high-performance liquid chromatography and gas chromatography-mass spectrometry (GC-MS) for the isolation of the nonsteroidal anti-inflammatory drug, ketorolac. The drug is isolated from postmortem blood using a batched solid-phase extraction method on Amberlite XAD-2 resin. Derivatization of ketorolac using diazopropane was necessary prior to GC-MS analysis. The methods were applied in the investigation of a death occurring shortly after the administration of an intramuscular injection of ketorolac tromethamine. Death was attributed to an adverse reaction to the drug, resulting in anaphylaxis and cardiac arrest.

Intramuscular Toradol, gastrointestinal bleeding, and peptic ulcer perforation: a case report

Peptic ulcers, perforations, and serious gastrointestinal bleeding have not been reported with intramuscular ketoralac tromethamine, the first parenteral nonsteroidal anti-inflammatory drug available for analgesic use. This article presents the case of a 39-year-old black female who underwent surgical repair of a perforated gastric ulcer after receiving multiple dosages of intramuscular ketoralac tromethamine in the emergency room over a period of 21/2 months for the treatment of pain due to chronic pancreatitis.

A double-blind evaluation of ketorolac tromethamine versus acetaminophen in pediatric tonsillectomy: analgesia and bleeding

The study was designed to compare intravenous ketorolac to rectal acetaminophen for analgesia and bleeding in pediatric patients undergoing tonsillectomy. We studied 50 patients, aged 2-15 yr undergoing tonsillectomy with or without adenoidectomy. In a randomized, prospective double-blind fashion, patients were assigned to receive either ketorolac (1 mg/kg) or rectal acetaminophen (35 mg/kg). Bleeding was evaluated by measuring intraoperative blood loss and noting extra measures required to obtain hemostasis. Bleeding times were also measured before and during surgery. Pain was evaluated using a standard objective pain score for the first 3 h. Persistent pain was treated with morphine, acetaminophen, and codeine and recorded for 24 h. Blood for determination of acetaminophen levels was drawn at 20 and 40 min after the administration of study drugs. Pain scores were not significantly different between the ketorolac and acetaminophen groups. The majority of patients in both groups required additional opioid in the postoperative period. Acetaminophen levels were all less than the therapeutic range. Intraoperative bleeding times were normal in all patients, but blood loss was significantly higher in the ketorolac group (2.67 mL/kg) compared to the acetaminophen group (1.44 mL/kg), P = 0.025. Significantly more measures to achieve hemostasis were required in the ketorolac group (P = 0.012). We conclude that ketorolac is no more effective than high-dose rectal acetaminophen for analgesia in the patient undergoing tonsillectomy. Hemostasis during tonsillectomy was significantly more difficult to achieve in patients receiving ketorolac.

Comparison of intravenous ketorolac and alfentanil as supplements to propofol anesthesia for diagnostic panendoscopy

STUDY OBJECTIVE

To determine if ketorolac tromethamine is an acceptable alternative to alfentanil as a supplement to propofol for diagnostic panendoscopy.

DESIGN

Randomized, double-blind study.

SETTING

University medical center.

PATIENTS

40 patients scheduled for panendoscopy and laryngeal tissue biopsy.

INTERVENTIONS

Patients were randomly assigned to receive either alfentanil 14.5 micrograms/kg or ketorolac 1.0 mg/kg in a double-blind fashion, 5 to 10 minutes before induction of general anesthesia.

MEASUREMENTS AND MAIN RESULTS

Heart rate (HR) and noninvasive blood pressure (BP) were measured and recorded before and immediately after injection of the study drug, after laryngoscopy for the endotracheal tube placement, and after initiation of diagnostic panendoscopy. Bleeding in the operative field was rated by the endoscopist. Observation from discontinuation of the propofol infusion and nitrous oxide inhalation to eye opening, head lifting, and orientation to time and place was observed and recorded. The presence of stridor after extubation, and pulse oximeter-determined arterial blood oxyhemoglobin saturation immediately after extubation and 5 minutes later, were noted. In the recovery room, the ability to tolerate oral fluids, sit, stand, and walk were recorded. Supplementation with ketorolac provides faster recovery from anesthesia as evidenced by shorter time to eye opening, head lifting, and orientation to time and place. However, no intergroup differences were found in measured intraoperative variables (BP and HR following laryngoscopy, tracheal intubation, diagnostic panendoscopy, and tissue biopsy). Operative site bleeding was comparable in both groups. The variables reflecting street readiness and the incidence of nausea and vomiting were statistically comparable.

CONCLUSION

Supplementation of propofol anesthesia with ketorolac is an efficacious alternative to supplementation with alfentanil. The faster recovery in the ketorolac group is explained by the mostly peripheral effect of this drug, whereas the slow decline in the alfentanil concentration at the effective site may be responsible for slower emergence from anesthesia.

Intramuscular ketorolac following total hip replacement with spinal anaesthesia and intrathecal morphine

We have studied the analgesic and morphine sparing effect of ketorolac tromethamine in 60 patients after total hip replacement under spinal anesthesia. In this double blind study 30 patients received ketorolac 30 mg IM 6 hourly postoperatively and the control group received saline. Analgesia was assessed by visual analogue pain scores (VAS) and morphine consumption by patient controlled analgesia (PCA). There was a significantly (P < 0.02) lower morphine consumption in the ketorolac group (7.1 +/- 8.6 mg; Mean +/- s.d.) when compared to the saline group (14.2 +/- 13.6 mg). Although there was a trend for lower VAS on the first postoperative night this was only significant at 10 hours postoperatively and the next morning at 08:00 hr. The incidence of side effects (emetic sequelae, pruritus and headache) were similar in both groups. It is concluded that ketorolac reduces the consumption of additional morphine in conjunction with intrathecal morphine but had no effects on the side effects.

Effect of ketorolac tromethamine (Toradol) on ecchymosis following anterior cruciate ligament reconstruction

This article describes a study that assesses whether patients who received ketorolac tromethamine (Toradol; Syntex Research, Palo Alto, California) during knee surgery had an increased tendency to develop ecchymosis in the lower limb versus patients who did not receive ketorolac tromethamine. Sixty-four patients who underwent anterior cruciate ligament (ACL) surgery were divided randomly into three groups: patients who received Toradol at tourniquet inflation (TorTourn) at the end of surgery (TorEnd), or not at all (TorNone). None of the patients exhibited abnormal preoperative bleeding times. One week postsurgery, patients were evaluated photographically for ecchymosis between the hip and malleoli of the surgical limb. Ecchymotic areas between the hip and malleoli were traced around their borders with a black marker. Three photographs of each surgical knee were taken: posterior, anterolateral, and anteromedial views. Each patient's photos then were scanned into a computer and the amount of encircled (ecchymotic) surface area and the total surface area of the limb were calculated. For each view, the ecchymotic surface area was divided by the total surface area to obtain a percentage of ecchymosis on that view. The percentages for the three views were added to obtain a single score for each patient. The mean ecchymotic surface area score was 21.9 +/- 31% for the TorTourn group, 27.5 +/- 25.5% for the TorEnd group, and 30.3 +/- 36.4% for the TorNone group. There was no significant difference in the ecchymotic surface area among the groups. This study suggests that ketorolac tromethamine does not affect the amount of ecchymosis that occurs following knee surgery.

Relationship between pharmacokinetics and the analgesic effect of ketorolac in the rat

The relationship between the pharmacokinetic properties and the analgesic effect of ketorolac was evaluated with the pain-induced functional impairment model in the rat. Female Wistar rats were injected with uric acid in the knee of the right hind limb to produce dysfunction. Then, animals received an oral dose of 0.3, 1, 1.8, 3.2 or 5.6 mg/kg of ketorolac tromethamine and analgesic effect and blood concentration, determined by high-performance liquid chromatography, were evaluated at selected times for a period of 4 hr. Ketorolac produced a dose-dependent analgesic effect, measured as a recovery of the functionality of the injured limb, which reached its maximal effect at doses of 3.2 mg/kg or higher. When functionality index was plotted against ketorolac blood concentration, a direct relationship was observed that was well described by the sigmoidal maximal effect model. The data strongly suggest that ketorolac's analgesic effect depends on the blood concentration of the drug.

Is there a clinical interaction between low molecular weight heparin and non-steroidal analgesics after total hip replacement?

The benefits of parenteral non-steroidal analgesic drugs and low molecular weight heparin anticoagulants have been shown before, but there is concern that the use of these agents in combination may potentiate haemorrhagic side-effects because of simultaneous inhibition of the clotting cascade and platelet mechanisms of haemostasis. In a prospective controlled trial, 60 patients undergoing total hip replacement were randomised into two groups. Those in one group received intramuscular ketorolac and those in the other group opioid analgesia. All patients received enoxaparin subcutaneously, once daily. There were 34 patients in the NSAID group and 26 in the opiate group. There were no significant differences between the two groups for intraoperative blood loss, postoperative drainage, transfusion requirements, bruising, wound oozing and leg swelling. From this study it would appear that there is a low risk of significant haemostatic potentiation associated with concurrent use of low molecular weight heparin and a modest dose of ketorolac tromethamine.

Effects of ketorolac tromethamine on erythropoietin levels in Sprague Dawley rats

Ketorolac tromethamine (KT) is a potent analgesic, most often used in its injectable form postoperatively. Similar to other nonsteroidal antiinflammatory drugs (NSAIDs), it inhibits prostaglandin (PG) synthesis. Prostaglandins have been shown to be involved in the regulation of renal function as well as erythropoietin (Ep) production. The intent of this study was to determine the effect of KT on plasma Ep levels in Sprague Dawley (SD) rats. Twenty rats received either 15 mg/kg/d or the KT vehicle IM for 5d. Blood samples (1 ml) were collected via tail vein each day of treatment. Plasma Ep levels were significantly higher in the KT rats than normal controls with the greatest difference occurring on d4 of treatment (70.1 +/- 10.8 vs 30.9 +/- 10.84 mU/ml, p < 0.01). This change in Ep corresponded with a significant reduction in hematocrit (KT, 29.5 +/- 2.2 vs C, 40.8 +/- 2.2%, p < 0.01). Presence of fecal blood was noted in the KT treated rats. A similar second experiment was designed to determine if blood loss was the cause of altered Ep production. In this experiment controls (HC) were bled via tail vein, to match the hematocrits of KT treated animals. Repeated administration of KT led to a steady reduction in hematocrit. When compared, hematocrit matched animals showed no difference in plasma Ep levels on all days of treatment (KT, 48.0 +/- 4.9 vs HC, 44.6 +/- 3.1 mU/ml, N.S.). In conclusion, repeated administration of KT showed no impairment of Ep production and release in response to reduced hematocrit, suggesting that in this instance, prostaglandin inhibition plays a minimal role in Ep production or release.

Ketorolac vs meperidine for the management of pain in the emergency department

OBJECTIVE

To compare the pain relief, sedation, and common side effect profiles of ketorolac tromethamine and meperidine for the management of acute pain in the emergency department (ED).

METHODS

A prospective, double-blind, randomized clinical trial was conducted over a 12-month period using consecutive adult patients presenting to a university teaching hospital ED (annual census: 32,000), who required IM analgesia for acute pain. Adult patients with acute pain of various etiologies were randomly assigned to receive a single fixed IM dose of ketorolac (60 mg) or meperidine (100 mg).

RESULTS

Ninety-three patients were enrolled in the study; 46 were randomized to meperidine and 47 to ketorolac. Using a visual analog scale, there was no difference in pain relief between the ketorolac and meperidine groups even after adjusting for baseline pain level. Ketorolac caused significantly (p < 0.005) less sedation than did meperidine at one hour. Rescue analgesia was required for seven of the 46 (15.2%) patients receiving meperidine and five of the 47 (10.6%) patients receiving ketorolac (p = NS). Seventeen of 45 (38%) patients receiving meperidine experienced side effects compared with eight of the 47 (17%) patients receiving ketorolac (p = 0.0452).

CONCLUSIONS

When used to treat patients who had acute pain states, 60 mg of IM ketorolac produced analgesia similar to that produced by 100 mg of IM meperidine; however, the ketorolac produced fewer subjective side effects and less sedation than did the meperidine.

Ketorolac tromethamine use in a university-based emergency department

OBJECTIVE

To assess the use of parenteral ketorolac tromethamine (KT) in the emergency department (ED).

METHODS

During a six-month period, KT was administered in an uncontrolled, nonblinded fashion to a series of ED patients experiencing acute pain. The patients rated pain on a previously validated visual analog pain scale before receiving KT. They repeated this procedure one hour after KT administration, prior to additional analgesia, or preceding release, whichever came first. Analgesic response was assessed by comparing pretreatment and posttreatment pain scores for the entire study population by the Wilcoxon rank sum test. Possible effects of specific variables (patient age, gender, race, indication for KT, route, dose, previous use of NSAIDs, and concurrent administration of muscle relaxants) were assessed using the Kruskal-Wallis test.

RESULTS

Of the 445 patients enrolled, 375 (84%) reported pain relief with KT, only seven (2%) worsened, and the remainder (14%) reported no change. Overall pain reduction was 37.6 +/- 27.2 (SD) mm (100-mm scale) for the entire study population. The pain scores obtained after KT administration were significantly lower than those obtained prior to KT administration (p < 0.001). The only variable that significantly influenced pain score reduction was indication for KT (p = 0.001). Nephrolithiasis and toothache patients had the largest mean reductions in pain. No significant side effect was reported.

CONCLUSION

Parenteral KT is a useful and safe analgesic for ED patients. The agent generally provides analgesia and is particularly promising for patients with nephrolithiasis or toothache.

Single-blind comparative analgesic and safety study of single doses of intramuscularly administered ketorolac tromethamine and pethidine hydrochloride in patients with pain following orthopaedic surgery

Ketorolac tromethamine, a potent non-narcotic prostaglandin synthetase inhibiting analgesic was compared with pethidine for relief of moderate to severe postoperative pain. Forty-eight patients received Ketorolac 0.5 mg/kg and 52 received pethidine 1.25 mg/kg. The degree of pain prior to the administration of the drug and pain relief that followed were quantified using a vertical visual analogue scale (VAS) and monitored at hourly intervals. The safety profile was also studied by recording all adverse events noted. The mean pain (VAS) score at medication for Ketorolac was 7.04 and for pethidine 7.09. The pain relief obtained in the first four hours following administration of the drugs was similar for pethidine and Ketorolac. Although Ketorolac showed a longer sustained pain relief, time to peak analgesia after administration of this drug was slower than that after pethidine. It took 30 to 50 min for pethidine compared to 75 to 150 min for Ketorolac to achieve peak analgesia. The latter is therefore inappropriate if rapid pain relief is required. The incidence of side effects was significantly greater with pethidine (40.4%) as compared to Ketorolac (10.4%). The similar analgesic efficacy to pethidine makes Ketorolac an appropriate drug for the relief of postoperative pain especially in day surgery settings where observation following administration of the drug as in the case of pethidine can be dispensed with and patients sent home earlier because of the minimal side effects associated with its use. Caution must be exercised with the use of large doses of Ketorolac especially if the drug is used for more than 5 days to avoid serious complications like renal failure and gastrointestinal bleeding.

Ketorolac-induced acute renal failure and hyperkalemia: report of three cases

Ketorolac tromethamine (Toradol, Syntex Laboratories Inc, Palo Alto, CA) is a new nonsteroidal anti-inflammatory drug widely used in emergency departments and during the postoperative period because of its potent analgesic effects and lack of central nervous system activities. We present three new cases of acute renal failure and hyperkalemia secondary to ketorolac. All patients had at least one risk factor making them prone to the development of acute renal failure secondary to the nonsteroidal anti-inflammatory drugs. In all patients, acute renal failure developed after a moderate dose of ketorolac was administered for the management of postsurgical pain. Acute renal failure and hyperkalemia were transient, and improved after discontinuation of ketorolac treatment.

The intraoperative administration of ketorolac tromethamine in evaluating length of stay in a same day surgery unit

This study was performed to determine if intraoperative administration of ketorolac tromethamine, a nonsteroidal anti-inflammatory drug, could shorten the length of stay in the same day surgery unit of a 535-bed medical center. Fifty laparoscopic patients were included in this study. Laparoscopic patients were chosen because they demonstrated an increased incidence of postoperative pain that delayed hospital discharge. The study population was divided into a test and control group. To eliminate procedural variability, the 50 subjects were chosen from a single group practice. Length of stay was recorded on a data retrieval form. Reasons for delay in discharge were identified. Subjects who received ketorolac tromethamine were discharged an average of 30 minutes earlier than those who did not receive it (94 minutes versus 124 minutes, respectively). A t-test revealed this difference to be statistically significant (P < or = .004). Intraoperative administration of ketorolac tromethamine should be considered for laparoscopy patients in same day surgery units, because criteria for discharge, such as stable vital signs, minimal nausea or vomiting, minimal pain, and oriented x 3 with a stable gait, are met sooner.

[Double-blind placebo-controlled study of the effectiveness and tolerability of 10 and 30 mg ketorolac tromethamine suppositories in post-cholecystectomy pain]

OBJECTIVE

To evaluate the efficacy and tolerability of ketorolac tromethamine 10 mg and 30 mg suppositories in comparison to placebo, after single dose administration in patients suffering from post-operative pain after cholecystectomy.

DESIGN

Double-blind, randomized, controlled study.

SETTING

Anaesthesia Service.

PATIENTS

99 patients with severe pain following surgery.

INTERVENTIONS

Cholecystectomy.

MEASUREMENTS AND MAIN RESULTS

The analgesia activity of ketorolac tromethamine 10 mg and 30 mg suppositories were evaluated after single dose administration by assessing pain intensity and pain relief using a 4 point scale (VRS). At the end of the treatment period overall assessment of safety and efficacy were recorded by physician and patient. The results show that in both active groups after 30' and until 4 hours, pain intensity decreased significantly with respect to the baseline. However a statistically significant difference between groups of p < 0.02, p < 0.01 and p < 0.05 was found in favour of the 30 mg dose respectively at 30', 6 and 8 hours after administration. All the patients treated with placebo suppositories required another rescue analgesic drug and withdrew from the trial. Three patients complained adverse events not related to treatment: two on placebo and one on ketorolac 10 mg. The systemic and local tolerability of the drug was good.

CONCLUSIONS

This study shows that ketorolac 30 mg suppositories are effective in clinical conditions, such as after surgery, in which pain control must be achieved within the shortest time interval and maintained or improved by means of a single route of administration.

Utilization of ketorolac tromethamine for control of severe odontogenic pain

Ketorolac tromethamine (KT) (Toradol, 60 mg to 2 ml), an injectable nonsteroidal anti-inflammatory drug, was compared with a placebo (sodium chloride, 0.9%) for analgesic effects in patients presenting with severe odontogenic pain. Utilizing a double-blind protocol, KT and placebo were administered and evaluated. Forty patients presenting with severe odontogenic pain (75 to 100 mm and above utilizing the visual analog scale of 100 mm) recorded their visual analog scale score once every 10 min for 90 min after injection of either KT or placebo and before initiating traditional incision and drainage, endodontic therapy, and/or extraction. Results indicate that KT patients had significantly less pain from 20 to 90 min postadministration than those receiving placebo. By the 90-min period, KT patients were reporting negligible discomfort. Observed side effects included lightheadedness and injection site pain. It was concluded that KT effectively reduces severe odontogenic pain within 40 min after administration in human subjects, with minimal side effects.

Intraoperative use of Toradol facilitates outpatient hemorrhoidectomy

Pain after hemorrhoidectomy is widely feared by many patients who are mostly still treated with oral/intramuscular narcotics to control their pain postoperatively.

PURPOSE

In an effort to decrease posthemorrhoidectomy pain by applying newer methods of analgesia, a prospective trial was conducted to investigate the postoperative analgesic effect of Toradol (ketorolac tromethamine; Syntex Labs, Palo Alto, CA) injected into the sphincter muscle at the time of hemorrhoidectomy and taken orally during a five-day postoperative period in a group of 24 patients (Toradol group). Results were compared with two other groups of matching patients: one group (narcotics, n = 18) treated with standard postoperative narcotic intramuscular/oral analgesics after overnight hospital stay, and a group (SQMP, n = 21) previously treated by one of us with outpatient, subcutaneous infusion of morphine sulfate (Roxane Laboratories, Columbus, OH) via a home infusion pump.

METHOD

The length of hospitalization, severity of postoperative pain and complications, costs, and side effects were analyzed by patient questionnaire at the time of the first postoperative visit and hospital and clinic records were reviewed. Differences between groups were analyzed using Student's t-test with P < 0.05 being significant.

RESULTS

Subjective pain response and hospitalization cost were significantly less in the SQMP group; however, this was at the expense of increased postoperative complications (urinary retention) and side effects (day until first bowel movement, nausea) although without a decrease in satisfaction rating. The Toradol group had pain control equivalent to that of the narcotics group, a higher satisfaction rating, and suffered no increase in complications relative to either group. Significantly, there was no urinary retention in the Toradol group.

CONCLUSION

Postoperative pain after hemorrhoidectomy can be safely controlled as an outpatient using newer methods of pain control. These include both constant-infusion pain pump or supplemental use of the nonsteroidal analgesic ketorolac, both of which allow early release of the patient the day of surgery by diminishing postoperative pain. An important advantage of local injection of ketorolac is the elimination of urinary retention in our study group, probably by blunting the pain reflex response facilitated by prostaglandins, thus allowing safe same-day discharge.

Tolerability, central effects and pharmacokinetics of intravenous ketorolac tromethamine in volunteers

The central effects, tolerability and pharmacokinetics of multiple intravenous doses of the analgesic ketorolac tromethamine (30 mg 4 times daily for 5 days) were studied in male volunteers. In this double-blind, randomized, parallel group study, 13 subjects received ketorolac tromethamine and 7 subjects received placebo (vehicle). To determine the effects of withdrawal all subjects were then given further dosing with placebo (4 times daily) for 2 days while maintaining the double-blind nature of the previous drug assignment. Physical examinations and laboratory tests were obtained prior to the drug administration and after completion of the study. Scales for assessment of anxiety, depression, sleep and opiate withdrawal were presented to the subjects on day 2, 5, 6, 7 and 8 of the study. After 5 days of multiple intravenous doses ketorolac showed overall good systemic tolerance and safety in comparison with placebo. Myalgia and taste perversion were more frequently reported in the ketorolac group. The frequency of injection site complaints, mostly transient pain, was about 80% for both ketorolac and placebo, indicating these were likely caused by the vehicle. There were no significant changes in the scales assessing anxiety, depression, sleep and opiate withdrawal during treatment with ketorolac and after its withdrawal, suggesting that the drug has neither any major central effects nor any clear addiction potential in this dose schedule. Pharmacokinetic parameters were derived from plasma samples collected after the first and last active doses.(ABSTRACT TRUNCATED AT 250 WORDS)

A multiple-dose, double-blind comparison of intramuscularly and orally administered ketorolac tromethamine and Ketogan in patients with pain following orthopaedic surgery

In this multiple-dose, double-blind study 100 patients with moderate, severe or very severe pain following orthopaedic surgery were randomly assigned to receive ketorolac, a non-steroidal anti-inflammatory drug with potent analgesic properties (10 mg), or the standard regimen of Ketogan (a combination product containing the narcotic analgesic, ketobemidone, plus a spasmolytic agent) by intramuscular injection every 1-6 h as needed for pain. When patients were able to tolerate an oral diet and were expected to respond to oral analgesic medication, based on overall pain sensitivity, they were switched to oral doses of the same medication every 4-6 h as needed. A maximum of four daily doses of medication was allowed for up to 10 days. The severity of pain was scored on a five-point scale and was recorded before the first intramuscular dose, at fixed time points thereafter for up to 6 h and at the end of each day. Both treatments were effective immediately after the first dose and during the subsequent multiple-dose phase. There were no statistically significant differences between ketorolac and Ketogan. The results show that 10-mg doses of ketorolac in intramuscular injections followed by 10-mg doses of oral ketorolac are as effective as Ketogan for the treatment of pain following orthopaedic surgery. Ketorolac appears to be better tolerated than Ketogan since significantly fewer patients reported adverse events (P = 0.004) when taking ketorolac.

Treatment of acute gouty arthritis with intramuscular ketorolac tromethamine

Nine consecutive patients presenting with acute gouty arthritis were treated with ketorolac 60 mg intramuscularly (IM). The average age was 58. Seven were male, and six were black. Pain was quantified in 6 of the patients using a 10-cm visual analog scale that the patients completed before and 30, 60, and 90 minutes after ketorolac administration. The mean pain score (+/- standard error of the mean) dropped from 6.43 (+/- 1.25), out of a possible 10, to 1.01 (+/- 35) (P < .01). There were no side effects of the medication. All of the patients were able to leave the treatment area satisfied with their treatment. None of the patients required crutches at discharge.

Enhancement of pain control with ketorolac tromethamine in patients with sickle cell vaso-occlusive crisis

Twenty one patients with sickle cell disease admitted to the hospital with the pain of vaso-occlusive crisis (VOC) were treated by continuous IV infusion of ketorolac or normal saline for up to 5 days. All patients received supplemental IM injections of meperidine, 100 mg, as necessary, but not more frequently than every 3 hr. Over the 5 days the ketorolac treated patients (KT) required 33% less meperidine than did the placebo treated patients (PL), P = 0.04, and had significantly better pain relief as assessed by categorical, visual analog, and pain relief scales. By the end of 5 days infusions had been discontinued in six KT and one PL. The time to discontinuation of the infusion was significantly shorter in KT, (P = 0.009). The median duration of hospital stay from the start of treatment was 3.3 days for KT and 7.2 days for PL, P = 0.027. Adverse events were mainly related to the digestive system. This study showed that continuous infusion of ketorolac significantly reduced total meperidine requirement and that the analgesia produced by this combination was superior to that produced by meperidine alone. Further evaluation of this drug in the management of sickle cell VOC is warranted.