Single-dose intramuscular ketorolac versus diclofenac for pain management in renal colic

Atomized Intranasal Ketorolac Versus Intravenous Ketorolac for the Treatment of Severe Renal Colic in the Emergency Department: A Double-Blind, Randomized Controlled Trial

STUDY OBJECTIVE

Atomized intranasal (IN) drug administration offers an alternative to the intravenous (IV) route. We aimed to evaluate the analgesic efficacy of IN versus IV ketorolac in emergency department patients with acute renal colic.

METHODS

We conducted a double-blind, randomized controlled trial on adult patients (aged 18 to 64 years) with severe renal colic and numerical rating scale pain ratings ≥7.0. They were randomly assigned (1:1) to receive single doses of either IN or IV ketorolac. Our main outcomes were differences in numerical rating scale reduction at 30 and 60 minutes. A 95% confidence interval (CI) was calculated for each mean difference, with a minimum clinically important difference set at 1.3 points. Secondary outcomes included treatment response, adverse events, rescue medications, and emergency department revisits. We analyzed using intention-to-treat.

RESULTS

A total of 86 and 85 patients with similar baseline characteristics were allocated to the IV and IN groups, respectively. Mean numerical rating scale scores were 8.52 and 8.65 at baseline, 3.85 and 4.67 at 30 minutes, and 2.80 and 3.04 at 90 minutes, respectively. The mean numerical rating scale reduction differences between the IV and IN groups were 0.69 (95% CI -0.08 to 1.48) at 30 minutes and 0.10 (95% CI -0.85 to 1.04) at 60 minutes. There were no differences in secondary outcomes.

CONCLUSION

Neither IN or IV ketorolac was superior to the other for the treatment of acute renal colic, and both provided clinically meaningful reductions in pain scores at 30 to 60 minutes.

Comparison of intravenous ketorolac at three doses for treating renal colic in the emergency department: A noninferiority randomized controlled trial

BACKGROUND

Ketorolac tromethamine is a nonsteroidal anti-inflammatory drug (NSAID) that is extensively used for the management of renal colic in the emergency department (ED). It has been proposed that ketorolac is used at doses above its analgesic ceiling with no more advantages and increased risk of adverse effects. In this study, we compared the analgesic effects of three doses of intravenous ketorolac in patients with renal colic.

METHODS

This noninferiority, randomized, double-blind clinical trial evaluated the analgesic efficacy of three doses of intravenous ketorolac (10, 20, and 30 mg) in adult patients presenting to the ED with renal colic. Exclusion criteria consisted of age > 65 years, active peptic ulcer disease, acute gastrointestinal hemorrhage, renal or hepatic insufficiency, NSAID hypersensitivity, pregnancy or breastfeeding, unstable vital signs, and patients who had received analgesics in the past 24 hours. Pain was recorded every 15 minutes from baseline up to 60 minutes, and the primary outcome was pain reduction at 30 minutes. If patients still required additional pain medications at 30 minutes, they would receive 0.1 mg/kg intravenous morphine sulfate as a rescue analgesic.

RESULTS

A total of 165 subjects enrolled in this study, 55 in each group. The median visual analog scale score in 30 minutes was improved from 90 at baseline to 40 among subjects who were randomized to 30-mg group. This improvement was 40 and 50 mm in 20- and 10-mg ketorolac treatment arms, respectively, with no significant difference between the three doses (p < 0.05). Secondary outcomes showed similar rescue analgesic administration and adverse effects. There was no serious adverse event.

CONCLUSION

Ketorolac at 10-, 20-, and 30-mg doses can produce similar analgesic efficacy in renal colic.

Comparison of Intravenous Ibuprofen with Intravenous Ketorolac in Renal Colic Pain Management; A Clinical Trial

Background

Choosing a proper medication for pain management of patients with acute renal colic has been a challenge for physicians treating these patients.

Objectives

The present study was performed with the aim of comparing intravenous (IV) ibuprofen and IV ketorolac in pain management of these patients.

Methods

In the present double-blind clinical trial study, patients suspected with renal colic presented to the emergency department were randomly divided into 2 groups receiving IV ibuprofen or IV ketorolac and were compared regarding effectiveness (pain reduction 15, 30, and 60 minutes after injection), treatment success, and possible side effects.

Results

In total, 240 patients suspected with renal colic with the mean age of 27.38 ± 12.32 years were randomly divided into 2 groups of 120 individuals treated with IV ketorolac or ibuprofen (66.4% male). The two groups were in a similar condition regarding age (P = 0.56), sex (P = 0.78) history of kidney stone (P = 0.40), vital signs (P > 0.05), stone size (P = 0.73), stone location (P = 0.13), and pain severity on admission (P = 0.32). 15, 30, and 60 minutes after drug injection, pain severity in the ketorolac group was significantly higher than the group receiving ibuprofen (P < 0.0001 for all comparisons), yet these differences were not clinically significant. Fifteen minutes after the injection, the rate of treatment success was significantly higher in the group receiving IV ibuprofen (P < 0.0001). After 60 minutes, the number of completely relieved cases reached 37 (30.8%) patients in the ketorolac group and 83 (69.1%) patients in the ibuprofen group. No significant difference was seen in side effects between the two groups (P = 0.35).

Conclusions

The findings of the present study show that ibuprofen is a more rapid acting drug compared to ketorolac in controlling pain caused by renal colic. In addition, its rate of complete relief from pain was twice as much as that of ketorolac. Since the side effects observed for ibuprofen in the present study were very mild, it is suggested to use this drug in treatment and pain control of renal colic patients.

A Prospective, Randomised Clinical Trial Comparing Oral Diclofenac Potassium and Intramuscular Diclofenac Sodium in Acute Pain Relief

Objectives

To compare the efficacy of oral (PO) diclofenac potassium (Cataflam®) and intramuscular (IM) diclofenac sodium (Voltaren®) in acute pain relief, with a hypothesis of equivalence between the two.

Patients and methods

In this prospective randomised single center clinical study, adult Chinese patients attending the emergency department and suffering from renal colic, acute musculoskeletal injury or arthritis were enrolled. They were randomly assigned either 75 mg of IM Voltaren® or 75 mg of PO Cataflam®. Pain was assessed by the Visual Analogue Scale (VAS) and evaluations were performed at baseline, 30 minutes, 1 hour and 2 hours after treatment. Blood pressure, pulse rate and respiratory rate were also recorded at similar time intervals.

Results

We recruited 46 cases in the Voltaren® group and 45 cases in the Cataflam® group. Both treatment groups showed statistically highly significant reduction (P<0.0001) in pain VAS, systolic blood pressure and pulse rate compared with the baseline. Voltaren® was statistically more effective in pain relief at 30 minutes (P=0.012) and 1 hour (P=0.010) but not at 2 hours (P=0.311) compared with Cataflam®. The changes in blood pressure, pulse rate and respiratory rate were not statistically significant between the two treatment groups at all time points.

Conclusion

IM Voltaren® was more effective in acute pain relief compared with PO Cataflam®.

Delivering safe and effective analgesia for management of renal colic in the emergency department: a double-blind, multigroup, randomised controlled trial

BACKGROUND

The excruciating pain of patients with renal colic on presentation to the emergency department requires effective analgesia to be administered in the shortest possible time. Trials comparing intramuscular non-steroidal anti-inflammatory drugs with intravenous opioids or paracetamol have been inconclusive because of the challenges associated with concealment of randomisation, small sample size, differences in outcome measures, and inadequate masking of participants and assessors. We did this trial to develop definitive evidence regarding the choice of initial analgesia and route of administration in participants presenting with renal colic to the emergency department.

METHODS

In this three-treatment group, double-blind, randomised controlled trial, adult participants (aged 18-65 years) presenting to the emergency department of an academic, tertiary care hospital in Qatar, with moderate to severe renal colic (Numerical pain Rating Scale ≥ 4) were recruited. With the use of computer-generated block randomisation (block sizes of six and nine), participants were assigned (1:1:1) to receive diclofenac (75 mg/3 mL intramuscular), morphine (0.1 mg/kg intravenous), or paracetamol (1 g/100 mL intravenous). Participants, clinicians, and trial personnel were masked to treatment assignment. The primary outcome was the proportion of participants achieving at least a 50% reduction in initial pain score at 30 min after analgesia, assessed by intention-to-treat analysis and per-protocol analysis, which included patients where a calculus in the urinary tract was detected with imaging. This trial is registered with ClinicalTrials.gov, number NCT02187614.

FINDINGS

Between Aug 5, 2014, and March 15, 2015, we randomly assigned 1645 participants, of whom 1644 were included in the intention-to-treat analysis (547 in the diclofenac group, 548 in the paracetemol group, and 549 in the morphine group). Ureteric calculi were detected in 1316 patients, who were analysed as the per-protocol population (438 in the diclofenac group, 435 in the paracetemol group, and 443 in the morphine group). The primary outcome was achieved in 371 (68%) patients in the diclofenac group, 364 (66%) in the paracetamol group, and 335 (61%) in the morphine group in the intention-to-treat population. Compared to morphine, diclofenac was significantly more effective in achieving the primary outcome (odds ratio [OR] 1·35, 95% CI 1·05-1·73, p=0·0187), whereas no difference was detected in the effectiveness of morphine compared with intravenous paracetamol (1·26, 0·99-1·62, p=0·0629). In the per-protocol population, diclofenac (OR 1·49, 95% CI 1·13-1·97, p=0·0046) and paracetamol (1·40, 1·06-1·85, p=0·0166) were more effective than morphine in achieving the primary outcome. Acute adverse events in the morphine group occurred in 19 (3%) participants. Significantly lower numbers of adverse events were recorded in the diclofenac group (7 [1%] participants, OR 0·31, 95% CI 0·12-0·78, p=0·0088) and paracetamol group (7 [1%] participants, 0·36, 0·15-0·87, p=0·0175) than in the morphine group. During the 2 week follow-up, no additional adverse events were noted in any group.

INTERPRETATION

Intramuscular non-steroidal anti-inflammatory drugs offer the most effective sustained analgesia for renal colic in the emergency department and seem to have fewer side-effects.

FUNDING

Hamad Medical Corporation Medical Research Center, Doha, Qatar.

Nonsteroidal anti-inflammatory drugs (NSAIDs) and non-opioids for acute renal colic

BACKGROUND

Renal colic is acute pain caused by urinary stones. The prevalence of urinary stones is between 10% and 15% in the United States, making renal colic one of the common reasons for urgent urological care. The pain is usually severe and the first step in the management is adequate analgesia. Many different classes of medications have been used in this regard including non-steroidal anti-inflammatory drugs and narcotics.

OBJECTIVES

The aim of this review was to assess benefits and harms of different NSAIDs and non-opioids in the treatment of adult patients with acute renal colic and if possible to determine which medication (or class of medications) are more appropriate for this purpose. Clinically relevant outcomes such as efficacy of pain relief, time to pain relief, recurrence of pain, need for rescue medication and side effects were explored.

SEARCH METHODS

We searched the Cochrane Renal Group's Specialised Register (to 27 November 2014) through contact with the Trials' Search Co-ordinator using search terms relevant to this review.

SELECTION CRITERIA

Only randomised or quasi randomised studies were included. Other inclusion criteria included adult patients with a clinical diagnosis of renal colic due to urolithiasis, at least one treatment arm included a non-narcotic analgesic compared to placebo or another non-narcotic drug, and reporting of pain outcome or medication adverse effect. Patient-rated pain by a validated tool, time to relief, need for rescue medication and pain recurrence constituted the outcomes of interest. Any adverse effects (minor or major) reported in the studies were included.

DATA COLLECTION AND ANALYSIS

Abstracts were reviewed by at least two authors independently. Papers meeting the inclusion criteria were fully reviewed and relevant data were recorded in a standardized Cochrane Renal Group data collection form. For dichotomous outcomes relative risks and 95% confidence intervals were calculated. For continuous outcomes the weighted mean difference was estimated. Both fixed and random models were used for meta-analysis. We assessed the analgesic effects using four different outcome variables: patient-reported pain relief using a visual analogue scale (VAS); proportion of patients with at least 50% reduction in pain; need for rescue medication; and pain recurrence. Heterogeneity was assessed using the I² test.

MAIN RESULTS

A total of 50 studies (5734 participants) were included in this review and 37 studies (4483 participants) contributed to our meta-analyses. Selection bias was low in 34% of the studies or unclear in 66%; performance bias was low in 74%, high in 14% and unclear in 12%; attrition bias was low in 82% and high in 18%; selective reporting bias low in 92% of the studies; and other biases (industry funding) was high in 4%, unclear in 18% and low in 78%.Patient-reported pain (VAS) results varied widely with high heterogeneity observed. For those comparisons which could be pooled we observed the following: NSAIDs significantly reduced pain compared to antispasmodics (5 studies, 303 participants: MD -12.97, 95% CI -21.80 to - 4.14; I² = 74%) and combination therapy of NSAIDs plus antispasmodics was significantly more effective in pain control than NSAID alone (2 studies, 310 participants: MD -1.99, 95% CI -2.58 to -1.40; I² = 0%).NSAIDs were significantly more effective than placebo in reducing pain by 50% within the first hour (3 studies, 197 participants: RR 2.28, 95% CI 1.47 to 3.51; I² = 15%). Indomethacin was found to be less effective than other NSAIDs (4 studies, 412 participants: RR 1.27, 95% CI 1.01 to 1.60; I² = 55%). NSAIDs were significantly more effective than hyoscine in pain reduction (5 comparisons, 196 participants: RR 2.44, 95% CI 1.61 to 3.70; I² = 28%). The combination of NSAIDs and antispasmodics was not superior to NSAIDs only (9 comparisons, 906 participants: RR 1.00, 95% CI 0.89 to 1.13; I² = 59%). The results were mixed when NSAIDs were compared to other non-opioid medications.When the need for rescue medication was evaluated, Patients receiving NSAIDs were significantly less likely to require rescue medicine than those receiving placebo (4 comparisons, 180 participants: RR 0.35, 95% CI 0.20 to 0.60; I² = 24%) and NSAIDs were more effective than antispasmodics (4 studies, 299 participants: RR 0.34, 95% CI 0.14 to 0.84; I² = 65%). Combination of NSAIDs and antispasmodics was not superior to NSAIDs (7 comparisons, 589 participants: RR 0.99, 95% CI 0.62 to 1.57; I² = 10%). Indomethacin was less effective than other NSAIDs (4 studies, 517 participants: RR 1.36, 95% CI 0.96 to 1.94; I² = 14%) except for lysine acetyl salicylate (RR 0.15, 95% CI 0.04 to 0.65).Pain recurrence was reported by only three studies which could not be pooled: a higher proportion of patients treated with 75 mg diclofenac (IM) showed pain recurrence in the first 24 hours of follow-up compared to those treated with 40 mg piroxicam (IM) (60 participants: RR 0.05, 95% CI 0.00 to 0.81); no significant difference in pain recurrence at 72 hours was observed between piroxicam plus phloroglucinol and piroxicam plus placebo groups (253 participants: RR 2.52, 95% CI 0.15 to12.75); and there was no significant difference in pain recurrence within 72 hours of discharge between IM piroxicam and IV paracetamol (82 participants: RR 1.00, 95% CI 0.65 to 1.54).Side effects were presented inconsistently, but no major events were reported.

AUTHORS' CONCLUSIONS

Although due to variability in studies (inclusion criteria, outcome variables and interventions) and the evidence is not of highest quality, we still believe that NSAIDs are an effective treatment for renal colic when compared to placebo or antispasmodics. The addition of antispasmodics to NSAIDS does not result in better pain control. Data on other types of non-opioid, non-NSAID medication was scarce.Major adverse effects are not reported in the literature for the use of NSAIDs for treatment of renal colic.

Nonsteroidal anti-inflammatory drugs (NSAIDs) versus opioids for acute renal colic

BACKGROUND

Renal colic is a common cause of acute severe pain. Both opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended for treatment, but the relative efficacy of these drugs is uncertain.

OBJECTIVES

To examine the benefits and disadvantages of NSAIDs and opioids for the management of pain in acute renal colic.

SEARCH STRATEGY

We searched the Cochrane Renal Group's specialised register (May 2003), the Cochrane Central Register of Randomised Controlled Trials (CENTRAL - The Cochrane Library issue 2, 2003), MEDLINE (1966 - 31 January 2003), EMBASE (1980 - 31 January 2003) and handsearched reference lists of retrieved articles. Most recent search date: January 2005

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing any opioid with any NSAID, regardless of dose or route of administration were included.

DATA COLLECTION AND ANALYSIS

Data was extracted and quality assessed independently by two reviewers, with differences resolved by discussion. Dichotomous outcomes are reported as relative risk (RR) and measurements on continuous scales are reported as weighted mean differences (WMD) with 95% confidence intervals. Subgroup analysis by study quality, drug type and drug route have been performed where possible to explore reasons for heterogeneity.

MAIN RESULTS

Twenty trials from nine countries with a total of 1613 participants were identified. Both NSAIDs and opioids lead to clinically significant falls in patient-reported pain scores. Due to unexplained heterogeneity these results could not be pooled although 10/13 studies reported lower pain scores in patients receiving NSAIDs. Patients treated with NSAIDs were significantly less likely to require rescue medication (RR 0.75, 95% CI 0.61 to 0.93, P = 0.007), though most of these trials used pethidine. The majority of trials showed a higher incidence of adverse events in patients treated with opioids, but there was significant heterogeneity between studies so the results could not be pooled. There was significantly less vomiting in patients treated with NSAIDs (RR 0.35, 95% CI 0.23 to 0.53, P < 0.00001). In particular, patients receiving pethidine had a much higher rate of vomiting compared with patients receiving NSAIDs. Gastrointestinal bleeding and renal impairment were not reported.

AUTHORS' CONCLUSIONS

Both NSAIDs and opioids can provide effective analgesia in acute renal colic. Opioids are associated with a higher incidence of adverse events, particularly vomiting. Given the high rate of vomiting associated with the use of opioids, particularly pethidine, and the greater likelihood of requiring further analgesia, we recommend that if an opioid is to be used it should not be pethidine.

Intramuscular Etofenamate versus Diclofenac in the Relief of Renal Colic

OBJECTIVE

To compare the efficacy and adverse effects of intramuscular etofenamate and intramuscular diclofenac in the relief of acute renal colic.

PATIENTS AND METHODS

A multicentre, randomised, single-blind study was performed in 119 patients admitted to the emergency room for renal colic. Patients were assigned to treatment with either etofenamate 1000mg or diclofenac 75mg, both administered intramuscularly. Pain was self-assessed using a 4-point verbal rating scale (VRS) and a visual analogue scale (VAS) just before drug administration and 30, 60, 120 and 240 min later.

RESULTS

The two groups were similar with regard to baseline characteristics. The percentages of patients who reported an improvement in the VRS at 60 min post-administration (primary variable) were 84.5% with etofenamate and 83.3% with diclofenac (p = 0.73). At the other timepoints (30, 120 and 240 min), the proportions of patients improved were, respectively, 69.5%, 82.6% and 79.3% in the etofenamate group, and 75.0%, 81.7% and 80.0% in the diclofenac group. The VAS score showed a statistically significant improvement in both groups, but no differences between groups were found.Analgesic rescue medication was required by 11 (18.6%) patients in the etofenamate group and by 12 (20.0%) patients in the diclofenac group. Mild to moderate adverse events were reported by 3.4% of patients receiving etofenamate and by 5.0% of patients receiving diclofenac.

CONCLUSION

Etofenamate and diclofenac were similarly effective and tolerated in the relief of acute renal colic.

Ondansetron versus diclofenac sodium in the treatment of acute ureteral colic: a double blind controlled trial

The aim of this study is to compare the effectiveness of the 5-HT3 antagonist, ondansetron and a non-steroidal anti-inflammatory agent, diclofenac sodium, as a pain reliever in the treatment of acute ureteral colic. Sixty four patients with severe or moderate pain who were clinically diagnosed as having ureteral colic associated with microscopic or gross hematuria were included in the study. Thirty three patients were administered ondansetron and 31 patients were administered diclofenac sodium. Exclusion critera were known kidney or liver disease causing dysfunction, known hypersensitivity to ondansetron or diclofenac sodium, pregnancy, lactation, duodenal ulcer or bleeding. After pain assessment with a verbal scale and a visual analog scale (VAS), we randomized patients and administered 8 mg ondansetron intravenously to 33 patients and 75 mg diclofenac sodium intramuscularly to 31 patients and pain scores were recorded every 15 minutes. If significant pain relief was not achieved within 60 minutes, i.v. meperidine was given as rescue pain medication. Ondansetron was effective as a primary pain reliever in 14 (42.4%) patients, whereas 19 patients required additional medication. Diclofenac sodium was effective as a primary pain reliever in 24 (77.4%) patients, whereas 7 patients required additional medication. Ondansetron was not superior to diclofenac sodium in relieving pain in patients with acute ureteral colic.

Intramuscular ketorolac vs oral ibuprofen in emergency department patients with acute pain

OBJECTIVE

To determine whether i.m. ketorolac is superior to oral ibuprofen in patients presenting to an ED in moderate to severe pain.

METHODS

This prospective, randomized, double-blind study involved a convenience sample of 119 patients aged > or = 18 years who presented to an urban teaching hospital ED with a self-assessed pain intensity score of 5, 6, 7, or 8 (on a numerical rating scale of 0-10). Patients were randomized to receive either 60 mg of i.m. ketorolac and a placebo capsule or 800 mg of oral ibuprofen and a saline injection. Pain scores were measured at 0, 15, 30, 45, 60, 90, and 120 minutes after dosing. Supplemental analgesics were allowed in accordance with standard medical practice.

RESULTS

There were 18 patients excluded who did not remain in the ED for the full 2-hour study period. Of those completing the trial, 53 patients received ketorolac and 48 patients received ibuprofen. There were no significant differences in pain scores between ketorolac and ibuprofen at any time during the study. However, there was a statistically significant decrease in pain over time in both treatment groups. Yet, 40% of the patients continued to report pain intensity scores of 5-8 at 2 hours after treatment.

CONCLUSIONS

I.m. ketorolac and oral ibuprofen provide comparable levels of analgesia in ED patients presenting with moderate to severe pain. Unfortunately, 40% of all the patients had inadequate pain relief (pain score > or = 5) from either ketorolac or ibuprofen.

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.