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

Perioperative systemic nonsteroidal anti-inflammatory drugs (NSAIDs) in women undergoing breast surgery

BACKGROUND

Breast surgery encompasses oncologic, reconstructive, and cosmetic procedures. With the recent focus on the over-prescribing of opioids in the literature, it is important to assess the effectiveness and safety of non-opioid pain medication regimens including nonsteroidal anti-inflammatory drugs (NSAIDs) or NSAID pain medications. Clinicians have differing opinions on the safety of perioperative (relating to, occurring in, or being the period around the time of a surgical operation) NSAIDs for breast surgery given the unclear risk/benefit ratio. NSAIDs have been shown to decrease inflammation, pain, and fever, while potentially increasing the risks of bleeding complications.

OBJECTIVES

To assess the effects of perioperative NSAID use versus non-NSAID analgesics (other pain medications) in women undergoing any form of breast surgery.

SEARCH METHODS

The Cochrane Breast Information Specialist searched the Cochrane Breast Cancer Group (CBCG) Specialized Register, CENTRAL (the Cochrane Library), MEDLINE, Embase, The WHO International Clinical Trials Registry Platform (ICTRP) and Clinicaltrials.gov registries to 21 September 2020. Full articles were retrieved for potentially eligible trials.

SELECTION CRITERIA

We considered all randomized controlled trials (RCTs) looking at perioperative NSAID use in women undergoing breast surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies, extracted data and assessed risk of bias, and certainty of the evidence using the GRADE approach. The main outcomes were incidence of breast hematoma within 90 days (requiring reoperation, interventional drainage, or no treatment) of breast surgery and pain intensity 24 hours following surgery, incidence rate or severity of postoperative nausea, vomiting or both, bleeding from any location within 90 days, need for blood transfusion, other side effects of NSAID use, opioid use within 24 hours of surgery, length of hospital stay, breast cancer recurrence, and non-prescribed NSAID use. Data were presented as risk ratios (RRs) for dichotomous outcomes and standardized mean differences (SMDs) for continuous outcomes.

MAIN RESULTS

We included 12 RCTs with a total of 1596 participants. Seven studies compared NSAIDs (ketorolac, diclofenac, flurbiprofen, parecoxib and celecoxib) to placebo. Four studies compared NSAIDs (ketorolac, flurbiprofen, ibuprofen, and celecoxib) to other analgesics (morphine, hydrocodone, hydromorphone, fentanyl). One study compared NSAIDs (diclofenac) to no intervention. NSAIDs compared to placebo Most outcomes are judged to have low-certainty evidence unless stated otherwise. There may be little to no difference in the incidence of breast hematomas within 90 days of breast surgery (RR 0.33, 95% confidence interval (CI) 0.05 to 2.02; 2 studies, 230 participants; I² = 0%). NSAIDs may reduce pain intensity 24 (± 12) hours following surgery compared to placebo (SMD -0.26, 95% CI -0.49 to -0.03; 3 studies, 310 participants; I² = 73%). There may be little to no difference in the incidence rates or severities of postoperative nausea, vomiting, or both (RR 1.15, 95% CI 0.58 to 2.27; 4 studies, 939 participants; I² = 81%), bleeding from any location within 90 days (RR 1.05, 95% CI 0.89 to 1.24; 2 studies, 251 participants; I² = 8%), or need for blood transfusion compared to placebo groups, but we are very uncertain (RR 4.62, 95% CI 0.23 to 91.34; 1 study, 48 participants; very low-certainty evidence). There may be no difference in other side effects (RR 1.12, 95% CI 0.44 to 2.86; 2 studies, 251 participants; I² = 0%). NSAIDs may reduce opioid use within 24 hours of surgery compared to placebo (SMD -0.45, 95% CI -0.85 to -0.05; 4 studies, 304 participants; I² = 63%). NSAIDs compared to other analgesics There is little to no difference in the incidence of breast hematomas within 90 days of breast surgery, but we are very uncertain (RR 0.33, 95% CI 0.01 to 7.99; 1 study, 100 participants; very low-certainty evidence). NSAIDs may reduce pain intensity 24 (± 12) hours following surgery (SMD -0.68, 95% CI -0.97 to -0.39; 3 studies, 200 participants; I² = 89%; low-certainty evidence) and probably reduce the incidence rates or severities of postoperative nausea, vomiting, or both compared to other analgesics (RR 0.18, 95% CI 0.06 to 0.57; 3 studies, 128 participants; I² = 0%; moderate-certainty evidence). There is little to no difference in the development of bleeding from any location within 90 days of breast surgery or in other side effects, but we are very uncertain (bleeding: RR 0.33, 95% CI 0.01 to 7.99; 1 study, 100 participants; other side effects: RR 0.11, 95% CI 0.01 to 1.80; 1 study, 48 participants; very low-certainty evidence). NSAIDs may reduce opioid use within 24 hours of surgery compared to other analgesics (SMD -6.87, 95% CI -10.93 to -2.81; 3 studies, 178 participants; I² = 96%; low-certainty evidence). NSAIDs compared to no intervention There is little to no difference in pain intensity 24 (± 12) hours following surgery compared to no intervention, but we are very uncertain (SMD -0.54, 95% CI -1.09 to 0.00; 1 study, 60 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

Low-certainty evidence suggests that NSAIDs may reduce postoperative pain, nausea and vomiting, and postoperative opioid use. However, there was very little evidence to indicate whether NSAIDs affect the rate of breast hematoma or bleeding from any location within 90 days of breast surgery, the need for blood transfusion and incidence of other side effects compared to placebo or other analgesics. High-quality large-scale RCTs are required before definitive conclusions can be made.

Inhibition of cyclooxygenase attenuates the blood pressure response to plantar flexion exercise in peripheral arterial disease

Prostanoids are produced during skeletal muscle contraction and subsequently stimulate muscle afferent nerves, thereby contributing to the exercise pressor reflex. Humans with peripheral arterial disease (PAD) have an augmented exercise pressor reflex, but the metabolite(s) responsible for this augmented response is not known. We tested the hypothesis that intravenous injection of ketorolac, which blocks the activity of cyclooxygenase, would attenuate the rise in mean arterial blood pressure (MAP) and heart rate (HR) evoked by plantar flexion exercise. Seven PAD patients underwent 4 min of single-leg dynamic plantar flexion (30 contractions/min) in the supine posture (workload: 0.5-2.0 kg). MAP and HR were measured on a beat-by-beat basis; changes from baseline in response to exercise were determined. Ketorolac did not affect MAP or HR at rest. During the first 20 s of exercise with the most symptomatic leg, ΔMAP was significantly attenuated by ketorolac (2 ± 2 mmHg) compared with control (8 ± 2 mmHg, P = 0.005), but ΔHR was similar (6 ± 2 vs. 5 ± 1 beats/min). Importantly, patients rated the exercise bout as "very light" to "fairly light," and average pain ratings were 1 of 10. Ketorolac had no effect on perceived exertion or pain ratings. Ketorolac also had no effect on MAP or HR in seven age- and sex-matched healthy subjects who performed a similar but longer plantar flexion protocol (workload: 0.5-7.0 kg). These data suggest that prostanoids contribute to the augmented exercise pressor reflex in patients with PAD.

Role of indomethacin in acute pain and inflammation management: a review of the literature

Nonsteroidal anti-inflammatory drugs are a class of analgesics that includes traditional nonselective and selective cyclooxygenase-2 inhibitors that block the biosynthesis of prostaglandins and thromboxane. Indomethacin is a nonsteroidal anti-inflammatory drug with potent antipyretic, analgesic, and anti-inflammatory activity that has been effectively used in the management of mild-to-moderate pain since the mid-1960s. It is commonly prescribed for the relief of acute gouty arthritis pain, but has demonstrated efficacy in the treatment of various other painful conditions. Numerous comparative studies have affirmed the clinical utility of indomethacin relative to other widely used analgesics. This review provides an historic overview of indomethacin and its efficacy compared with other commonly used analgesics, and discusses new indomethacin drug products.

The effect of ketorolac tromethamine, methylprednisolone, and platelet-rich plasma on human chondrocyte and tenocyte viability

PURPOSE

The purpose of this study was to evaluate the effect on cell viability of the isolated and combined use of allogeneic platelet-rich plasma (PRP) and ketorolac tromethamine on human chondrocytes and tenocytes in a highly controlled in vitro environment.

METHODS

PRP was produced from 8 subjects. Human chondrocytes (Lonza, Hopkinton, MA) and tenocytes isolated from samples of the long head of the biceps tendons were treated in culture with PRP, ketorolac tromethamine, and methylprednisolone, both alone and in combination. Control samples were treated in media containing 2% or 10% fetal bovine serum (FBS). Cells were exposed for 1 hour. Luminescence assays were obtained to examine cell viability after 24 hours and long-term effects on cell viability after 120 hours. Radioactive thymidine assay was used to measure proliferation after 120 hours.

RESULTS

For chondrocytes, cell viability (120 hours) increased significantly with the treatment of PRP alone (43,949 ± 28,104 cells; P < .001) and with the combination of ketorolac tromethamine and PRP (43,276 ± 31,208; P < .001), compared with the 2% FBS group (7,397 ± 470). Cell viability decreased significantly after exposure to methylprednisolone (1,323 ± 776; P < .001) and its combination with PRP (4,381 ± 5,116; p < .001). For tenocytes, cell viability (120 hours) was significantly higher with the treatment of PRP (61,287 ± 23,273; P < .001) and the combined treatment of ketorolac tromethamine and PRP (52,025 ± 17,307; P < .001), compared with the 2% FBS group (23,042 ± 2,973). Cell viability decreased significantly after exposure to methylprednisolone (3,934 ± 1,791; P = .001) and its combination with PRP (5,201 ± 2,834; P = .003), compared with 2% FBS.

CONCLUSIONS

Tendon and cartilage cells showed increased cell viability after an exposure to allogeneic PRP and ketorolac tromethamine. Exposure to methylprednisolone alone decreased cell viability, and addition of PRP could partially reverse this negative effect.

CLINICAL RELEVANCE

Intra-articular injections of pain-modifying or anti-inflammatory drugs are routinely given in orthopaedic practice. Among the many agents available for intra-articular injection, corticosteroids and local anesthetics are the most common in clinical practice. Potential detrimental side effects of intra-articular injections of corticosteroids and local anesthetics have prompted investigation into alternative treatment options such as combinations of PRP and ketorolac tromethamine. In vitro evaluation of their effect on cell viability might build a basis for further translational research and clinical application.

Effective analgesic modalities for ambulatory patients

The introduction of government-mandated standards for pain management has focused our attention on postoperative pain. With the recent JACHO standards' for ambulatory surgery, it is imperative that all health care workers who care for these patients are familiar with appropriate pain management. Developments in our understanding of the pathophysiology of acute pain have further enhanced our ability to improve pain management for postoperative ambulatory patients. This has led to the concept of preventive analgesia (inhibition of physiological and pathological secondary inflammatory pain). Extensive work has shown that this is best achieved using a multimodel approach usually consisting of an NSAID, opioid, and local anesthetic. NMDA antagonists (ketamine, dextromethorphan) and alpha-2 agnoists (clonodine) show potential supplements to further enhance pain management, especially if given preemptively. Nonpharmacological intervention such as cold therapy or acupuncture may also be considered. The armanentarium for effective pain management has improved substantially over the past few years. The challenge is for health care workers to implement these therapies to obtain optimum pain management in ambulatory surgical patients.

Use of indomethacin for pain relief following scleral buckling surgery

BACKGROUND/AIMS

Patients undergoing scleral buckling and cryotherapy suffer from mild to moderate postoperative pain. As good pain relief facilitates post-operative ocular examination, as well as patient comfort and recovery, the authors designed a prospective randomised double masked trial to evaluate the efficacy of indomethacin as a satisfactory analgesic for such patients.

METHOD

Patients with a primary uncomplicated rhegmatogenous retinal detachment requiring scleral buckling and cryotherapy were randomly allocated to receive either indomethacin or placebo. A rectal suppository was administered 2 hours before surgery, followed by two capsules twice daily for 10 days. Pain relief was assessed with a linear graphic rating scale at the end of each day. Supplementary analgesia was allowed and recorded.

RESULTS

12 patients received indomethacin (group A) and 16 received placebo (group B). The extent of surgery was similar in both groups. One patient in group A, and two in group B withdrew after 3 days. The pain scores were converted to changes from the baseline (score on day 1), and the area under the curve calculated for each patient. The means of the areas were analysed with the Mann-Whitney test and showed that indomethacin caused a statistically significant reduction in pain score, both at 3 days (p = 0.04) and at 10 days (p = 0.014). There was no statistically significant difference in extra analgesic requirements between the two groups (p = 0.2).

CONCLUSIONS

Indomethacin is recommended for short to medium term pain relief following scleral buckling and cryotherapy.

Comparing analgesic efficacy of non-steroidal anti-inflammatory drugs given by different routes in acute and chronic pain: a qualitative systematic review

AIM

To test the evidence for a difference in analgesic efficacy and adverse effects of non-steroidal anti-inflammatory drugs (NSAIDs) given by different routes.

METHODS

Systematic review of published randomised controlled trials. Relevant trials were comparisons of the same drug given by different routes. Presence of internal sensitivity was sought as a validity criterion. Analgesic and adverse effect outcomes were summarised, and synthesised qualitatively.

RESULTS

In 26 trials (2225 analysed patients), 8 different NSAIDs were tested in 58 comparisons. Fifteen trials (58%) compared the same drug by different routes. Drugs were given by intravenous, intramuscular, intrawound, rectal and oral routes in postoperative pain (14 trials), renal colic (4), acute musculoskeletal pain (1), dysmenorrhoea (1), and rheumatoid arthritis (6). Five of the 15 direct comparisons were invalid because they reported no difference between routes but without evidence of internal sensitivity. In all 3 direct comparisons in renal colic, intravenous NSAID had a faster onset of action than intramuscular or rectal. In 1 direct comparison in dysmenorrhoea, oral NSAID was better than rectal. In the 5 direct comparisons in postoperative pain, results were inconsistent. In 1 direct comparison in rheumatoid arthritis, intramuscular NSAID was better than oral. Injected and rectal administration had some specific adverse effects.

CONCLUSION

In renal colic there is evidence that NSAIDs act quickest when given intravenously. This may be clinically relevant. In all other pain conditions there is a lack of evidence of any difference between routes. In pain conditions other than renal colic, there is, therefore, a strong argument to give oral NSAIDs when patients can swallow.

Ketorolac. A reappraisal of its pharmacodynamic and pharmacokinetic properties and therapeutic use in pain management

Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) with strong analgesic activity. The analgesic efficacy of ketorolac has been extensively evaluated in the postoperative setting, in both hospital inpatients and outpatients, and in patients with various other acute pain states. After major abdominal, orthopaedic or gynaecological surgery or ambulatory laparoscopic or gynaecological procedures, ketorolac provides relief from mild to severe pain in the majority of patients and has similar analgesic efficacy to that of standard dosages of morphine and pethidine (meperidine) as well as less frequently used opioids and other NSAIDs. The analgesic effect of ketorolac may be slightly delayed but often persists for longer than that of opioids. Combined therapy with ketorolac and an opioid results in a 25 to 50% reduction in opioid requirements, and in some patients this is accompanied by a concomitant decrease in opioid-induced adverse events, more rapid return to normal gastrointestinal function and shorter stay in hospital. In children undergoing myringotomy, hernia repair, tonsillectomy, or other surgery associated with mild to moderate pain, ketorolac provides comparable analgesia to morphine, pethidine or paracetamol (acetaminophen). In the emergency department, ketorolac attenuates moderate to severe pain in patients with renal colic, migraine headache, musculoskeletal pain or sickle cell crisis and is usually as effective as frequently used opioids, such as morphine and pethidine, and other NSAIDs and analgesics. Subcutaneous administration of ketorolac reduces pain in patients with cancer and seems particularly beneficial in pain resulting from bone metastases. The acquisition cost of ketorolac is greater than that of morphine or pethidine; however, in a small number of studies, the higher cost of ketorolac was offset when treatment with ketorolac resulted in a reduced hospital stay compared with alternative opioid therapy. The tolerability profile of ketorolac parallels that of other NSAIDs; most clinically important adverse events affect the gastrointestinal tract and/or renal or haematological function. The incidence of serious or fatal adverse events reported with ketorolac has decreased since revision of dosage guidelines. Results from a large retrospective postmarketing surveillance study in more than 20,000 patients demonstrated that the overall risk of gastrointestinal or operative site bleeding related to parenteral ketorolac therapy was only slightly higher than with opioids. However, the risk increased markedly when high dosages were used for more than 5 days, especially in the elderly. Acute renal failure may occur after treatment with ketorolac but is usually reversible on drug discontinuation. In common with other NSAIDs, ketorolac has also been implicated in allergic or hypersensitivity reactions. In summary, ketorolac is a strong analgesic with a tolerability profile which resembles that of other NSAIDs. When used in accordance with current dosage guidelines, this drug provides a useful alternative, or adjuvant, to opioids in patients with moderate to severe pain.

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.

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.

Intramuscular ketorolac versus oral ibuprofen in acute musculoskeletal pain

STUDY OBJECTIVE

To evaluate the efficacy of IM ketorolac versus that of oral ibuprofen in acute musculoskeletal pain.

DESIGN

Randomized, prospective, double-blind clinical trial.

SETTING

Urban teaching emergency department with an annual census of 43,000.

PARTICIPANTS

Convenience sample of 82 patients aged 18 to 70 years with acute musculoskeletal pain due to trauma.

INTERVENTIONS

Forty-two subjects each received 60 mg ketorolac by IM injection and ingested a placebo capsule. Forty subjects each ingested 800 mg ibuprofen and received a placebo (saline) IM injection. Pain was evaluated with a 100-mm visual analog scale at baseline and 15, 30, 45, 60, 75, 90, and 120 minutes after dosing. The prevalence of side effects was elicited in each patient.

RESULTS

Mean pain scores improved in each group during the course of the study but did not significantly differ between groups at baseline or at any subsequent interval. The numbers of dropouts due to inadequate analgesia and prevalence of side effects in the two groups did not differ significantly.

CONCLUSION

IM ketorolac and oral ibuprofen provide comparable analgesia in ED patients with acute musculoskeletal pain.