Ketorolac induced acute renal failure following a single dose

Acute and chronic impairment of renal function have been reported as complications of therapy with nonsteroidal anti-inflammatory agents. Renal prostaglandins play an increasingly important role in maintaining renal function when there is decreased renal blood perfusion. We describe a case of rapidly appearing acute renal failure following a single intramuscular dose of ketorolac.

NSAID nephrotoxicity revisited: acute renal failure due to parenteral ketorolac

The success of ketorolac as a nonnarcotic analgesic is likely to propagate its widespread use to control moderate to severe postoperative pain. Indeed, of the patients treated with ketorolac and described in the medical literature, nearly 90% had had a major surgical procedure. Since any such procedure may be associated with significant third-spacing of the fluid and result in renal hypoperfusion, care must be taken in administering ketorolac. Close attention to urine output and parameters of renal function must be maintained. Moreover, postoperative ketorolac therapy should be avoided in patients who have conditions that predispose to NSAID nephrotoxicity (as in our Case 1). Likewise, in nonsurgical patients the same degree of caution should be used with ketorolac as with any oral NSAID. Finally, since ketorolac is excreted almost entirely by the kidney, either elderly patients or patients with underlying renal insufficiency must have an adjustment of the dosing interval, or this medication should be avoided in such patients altogether.

Ketorolac and indomethacin are equally efficacious for the relief of minor postoperative pain

Injectable ketorolac is an effective analgesic in ambulatory surgery patients. However, no studies have compared ketorolac with other NSAIDs in this setting. The analgesic efficacy of intramuscular ketorolac, rectal indomethacin and placebo was compared in healthy women undergoing gynaecological or breast surgery as outpatients. Ninety patients received 30 mg im ketorolac, 100 mg pr indomethacin or placebo in a prospective, randomized, double-blind manner. A standardized anaesthetic protocol was followed. Patients graded their pain on a 10 cm visual analogue scale in the recovery room, twice in the surgical day care unit and during the car ride home. The patients' postoperative fentanyl requirements, time to recovery milestones, and side effects were recorded. The placebo group received more fentanyl in the PACU but did not achieve the same pain relief as either of the NSAID-treated group (ketorolac 44 +/- 53 micrograms, indomethacin 39 +/- 55 micrograms, placebo 87 +/- 100 micrograms, P < 0.05). Patients who received an NSAID had less pain at 15 and 90 min (P < 0.05). The PACU stay was longer for the placebo group (ketorolac 50 +/- 13 min, indomethacin 49 +/- 12 min, placebo 62 +/- 35 min, P < 0.05). Time to ambulation was also longer in the placebo group (ketorolac 117 +/- 25 min, indomethacin 121 +/- 49 min, placebo 140 +/- 51 min, P < 0.05). However, no differences were observed between the two NSAIDS. Side effects were similar in all groups. We conclude that im ketorolac and pr indomethacin are equally effective analgesics in this group of patients.

[A double-blind study of the analgesic efficacy in kidney colic of the combination of dipyrone and spasmolytic with ketorolac trometamol]

We conducted a double-blind study in 34 patients to compare the analgesic efficacy in acute renal colic using 2.5 g dipyrone combined with a spasmolytic agent and 30 mg ketorolac tromethamine, diluted in 100 ml saline solution and injected intravenously. Clinical criteria and the observation of red cells in urine were used for the diagnosis. The intensity of the pain and its development were measured using visual analogue scales (VAS) and a scale of items showing patient improvement. The side effects were spontaneously mentioned by the patients and elicited by direct questioning. It can be confirmed with a beta error of 0.10 that the analgesic effect obtained by both treatments is similar. Nevertheless, the combination of dipyrone and spasmolytic produces more side effects, possibly due to the spasmolytic agent.

Ketorolac versus fentanyl for gynaecological day-case surgery

The effectiveness of fentanyl and ketorolac in providing analgesia for day-case gynaecological procedures was evaluated in 55 healthy volunteers in a single blinded fashion. Fentanyl (1 mcg/kg iv) and ketorolac (30 mg im) were administered immediately following induction of anaesthesia. Anaesthesia was standardized with propofol, nitrous oxide and enflurane. Outcome variables assessed were pain, additional analgesic requirements, and incidence of postoperative nausea and vomiting. All variables were recorded at 15 minutes, 2 hours and 24 hours postoperatively. There was no significant difference between the 2 groups with respect to any of the measured variables. Both drugs were ineffective as sole analgesic agents in half of their respective groups. It may be that a combination of these drugs, providing a multireceptor approach to analgesia, will prove to be more effective.

Examining product risk in context. Market withdrawal of zomepirac as a case study

OBJECTIVE

To examine changes in the prescribing of analgesics after the market entry and subsequent withdrawal of zomepirac sodium, a nonsteroidal anti-inflammatory drug (NSAID), following repeated reports of zomepirac-related deaths.

DESIGN

To evaluate this natural quasi experiment, we conducted time-series analyses to compare prescribing in two cohorts of primary care physicians from July 1980 through September 1983.

SETTING

Study physicians provided outpatient pharmaceutical care to patients enrolled in the New Jersey Medicaid program.

PARTICIPANTS

We identified 260 primary care physicians who provided 10 or more prescriptions for zomepirac (zomepirac prescribers) and 308 who provided 10 or more prescriptions for NSAIDs other than zomepirac (other-NSAID prescribers) in Medicaid during the study period.

MAIN OUTCOME MEASURES

Monthly rates of prescribing for zomepirac and several categories of substitute analgesics among Medicaid patients seen by study physicians.

MAIN RESULTS

Zomepirac accounted for a stable 11.0% of analgesic prescribing among the zomepirac-prescriber cohort; label changes and manufacturer product-risk warnings 11 months before the product's withdrawal from the market had no impact on use. After market entry, zomepirac prescribers reduced use of other NSAIDs and propoxyphene (hydrochloride or napsylate) in comparison with other-NSAID prescribers (-8.1% and -2.8% of total analgesic prescribing, respectively; P < .001). After the product's withdrawal from the market, zomepirac prescribers showed significant increases in relative prescribing of other NSAIDs (+6.8%; P < .001), propoxyphene (+2.1%; P < .05), and analgesics containing barbiturates (+2.7%; P < .001).

CONCLUSIONS

The sudden withdrawal of zomepirac from the market resulted in substitutions not only of other NSAIDs, but also of alternative analgesics that carry risks of habituation and adverse effects. Apparent gains in patient safety resulting from market withdrawal of medications must be evaluated in comparison with risks of medications likely to be substituted.

Respiratory depression following combination of epidural buprenorphine and intramuscular ketorolac

A 48-year-old man who had undergone thoracotomy for carcinoma of the middle third of his oesophagus developed severe postoperative respiratory depression following intramuscular ketorolac 30 mg 2 h after 150 micrograms epidural buprenorphine. Summation of analgesia by drugs used in combination can have deleterious respiratory effects.

Renal insufficiency associated with intramuscular administration of ketorolac tromethamine

OBJECTIVE

To evaluate reports of renal toxicity associated with intramuscular ketorolac tromethamine. Medical charts were reviewed for all cases of renal toxicity associated with ketorolac therapy.

METHODS

Patients with possible ketorolac-associated nephrotoxicity were identified through our institution's adverse drug reaction reporting program. Patients were included in this report if: (1) renal insufficiency was temporally related to ketorolac administration; (2) resolution of renal insufficiency occurred after discontinuation of ketorolac; and (3) no other causes of renal insufficiency, including other medications, could be identified.

RESULTS

Six patients had renal insufficiency secondary to ketorolac administration. The mean age of the patients was 58 years and cardiovascular disease was present in five. Serum creatinine values increased from a mean of 106 +/- 26 mumol/L (1.2 +/- 0.3 mg/dL) to a mean peak value of 256 +/- 195 mumol/L (2.9 +/- 2.2 mg/dL). Recovery of renal function was observed after a mean of 2.3 +/- 0.5 days.

CONCLUSIONS

Short-term administration of ketorolac can be associated with reversible oliguric renal insufficiency. Indiscriminate use of ketorolac for pain management in place of narcotic analgesics should be avoided, especially in patients at high risk for toxicity induced by nonsteroidal antiinflammatory drugs.

Double-masked, paired-comparison clinical study of ketorolac tromethamine 0.5% ophthalmic solution compared with placebo eyedrops in the treatment of seasonal allergic conjunctivitis

In a multicenter, double-masked, clinical study, we compared the ocular safety and efficacy of ketorolac 0.5% ophthalmic solution with placebo in alleviating the signs and symptoms of allergic conjunctivitis. The study was conducted in 93 patients who received one drop of the appropriate treatments in each eye, four times a day, for seven days. Of these subjects, 74 were evaluated for efficacy. The principal clinical sign of allergic conjunctivitis, conjunctival inflammation, and six allergic symptoms (itching, swollen eyes, burning or stinging, discharge or tearing, foreign body sensation, and photophobia) were evaluated by the investigators at midweek (day 3 or 4) and at the end of the study (day 7 or 8). Ketorolac was superior to placebo in reducing conjunctival inflammation (p = 0.003) and itching (p = 0.020), the principal clinical symptom, at the final examination. In addition, ketorolac was favored over placebo in reducing the other five symptoms evaluated. On the day of final examination, overall therapeutic response evaluated by the investigators rated ketorolac as superior to placebo (p = 0.007). A significant placebo effect was noted in this study, as has been previously reported in clinical studies of allergic conjunctivitis patients. Results of this study demonstrate that 0.5% ketorolac ophthalmic solution used topically four times daily, for seven days, was effective in alleviating the principal sign and the symptoms associated with allergic conjunctivitis.

Clinical evaluation of ketorolac tromethamine 0.5% ophthalmic solution for the treatment of seasonal allergic conjunctivitis

We evaluated 148 patients with allergic conjunctivitis in a double-masked, paired comparison clinical trial comparing ketorolac 0.5% ophthalmic solution with vehicle. Patients received one drop of each study medication in preassigned eyes, four times a day, for seven days. Both treatments showed significant changes from baseline in the signs and symptoms associated with allergic conjunctivitis. Evaluations at the final visit (day 7 or 8) showed that ketorolac-treated eyes had a significant treatment response when compared to vehicle-treated eyes for conjunctival inflammation (p = 0.010), ocular itching (p = 0.006), swollen eyes (p = 0.002), discharge/tearing (p = 0.021), foreign body sensation (p = 0.035), and conjunctival injection (p = 0.016). Mean scores evaluating the overall therapeutic effect of the study treatments at the completion of the study were higher for ketorolac-treated eyes than for vehicle-treated eyes as rated by investigators (p = 0.004) and study patients (p < 0.001). Results of this study confirmed the trends of a previous study showing that ketorolac 0.5% ophthalmic solution applied topically is an effective therapy for allergic conjunctivitis.

Ketorolac and diclofenac for postoperative pain relief following oral surgery

A double-blind clinical study was designed to compare the efficacy and safety of intramuscular and oral ketorolac, a new non-steroidal anti-inflammatory analgesic with that of diclofenac and placebo for patients undergoing removal of impacted mandibular third molar teeth. Results showed that both analgesic preparations were more effective than placebo (p = 0.0029) and that ketorolac provided a similar degree of pain relief to that of diclofenac. It is concluded that ketorolac is important new addition to the available intra-muscular NSAID preparations.

Comparison of ketorolac and meperidine in patients with postoperative pain--impact on health care utilization

A double-blind, randomized study was conducted to compare the effects of intramuscular ketorolac tromethamine and meperidine hydrochloride, and subsequent oral pain medication, on health care utilization and postoperative recovery. Following abdominal hysterectomy or cholecystectomy, 210 patients (aged 18 to 70 years; 189 women, 21 men) were randomly assigned to therapy and evaluated for efficacy, safety, nursing care requirements, functional independence, recovery milestones, and quality of life. The patients received 30 mg of ketorolac intramuscularly every 3 to 6 hours as needed, followed by 10 mg of ketorolac every 4 to 6 hours, or 100 mg of meperidine intramuscularly every 3 to 6 hours as needed, followed by acetaminophen/codeine (600 mg/60 mg) orally every 4 to 6 hours. Patients receiving ketorolac had lower nursing utilization scores and achieved a higher level of functioning than patients receiving meperidine during the first 3 postoperative days. Times to first bowel movement, walking without assistance, and first oral fluids were significantly shorter after ketorolac than meperidine. Mean pain intensity difference (from baseline) scores and pain relief scores when adjusted for baseline pain severity were comparable between ketorolac and meperidine. Most adverse events reported by the patients were mild to moderate; 12 patients in each group withdrew from treatment because of adverse events (nausea, rash, or headache). It is concluded that ketorolac is an effective alternative to meperidine in the management of postoperative pain.

Pain relief after dental impaction surgery using ketorolac, hydrocodone plus acetaminophen, or placebo

In a double-blind, placebo-controlled study, 207 patients with moderate pain after surgical removal of impacted third molars were randomly assigned to receive a single oral dose of 10 mg of ketorolac tromethamine, 10 mg of hydrocodone plus 1000 mg of acetaminophen, or placebo. Analgesic effect as assessed by summed pain intensity difference at 3 and 6 hours was significantly (P < or = 0.01) greater after ketorolac than after hydrocodone/acetaminophen. Total pain relief at 3 and 6 hours was significantly (P < 0.026) greater after ketorolac than after hydrocodone/acetaminophen or placebo. Patients taking hydrocodone/acetaminophen remedicated significantly (P = 0.027) sooner than those taking ketorolac. In this single-dose study, adverse events were reported more frequently by patients taking hydrocodone/acetaminophen than with ketorolac or placebo. It is concluded that, in this pain model, 10 mg of ketorolac affords better pain relief with fewer side effects than hydrocodone/acetaminophen.