Acute angioedema after ketorolac ingestion: report of case

Angioedema and swellings of the orofacial region

OBJECTIVE

Patients may have various forms of angioedema and require dental treatment which can cause or contribute to the onset of an episode of angioedema. This paper seeks to highlight the causes and the management of this serious condition.

DESIGN

An outline of the different types of angioedema is given here, along with three case reports which illustrate treatment and management.

SUBJECTS AND METHODS

Three patients who presented to an Oral Medicine clinic with angioedema are presented to illustrate various types of angioedema and the different contributing factors that precipitated episodes of the condition.

MAIN OUTCOME MEASURES

The three patients were all investigated for biochemical and allergic factors which may have caused their disease.

RESULTS

Both drugs and dental materials were shown to be involved in the pathogenesis of angioedema in this short series of patients.

CONCLUSIONS

Dental treatment or the use of some materials may promote or contribute to the disorder. Referral to hospital for specialist care is indicated for certain groups of patients who require invasive dental treatment. The multi-disciplinary team approach in the investigation and management of patients with angioedema is emphasised.

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.

Asthma caused by topical application of ketorolac

BACKGROUND

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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