Clinical implications of ketorolac for postoperative analgesia

Gastrointestinal-resident, shape-changing microdevices extend drug release in vivo

Extended-release gastrointestinal (GI) luminal delivery substantially increases the ease of administration of drugs and consequently the adherence to therapeutic regimens. However, because of clearance by intrinsic GI motility, device gastroretention and extended drug release over a prolonged duration are very challenging. Here, we report that GI parasite-inspired active mechanochemical therapeutic grippers, or theragrippers, can reside within the GI tract of live animals for 24 hours by autonomously latching onto the mucosal tissue. We also observe a notable sixfold increase in the elimination half-life using theragripper-mediated delivery of a model analgesic ketorolac tromethamine. These results provide first-in-class evidence that shape-changing and self-latching microdevices enhance the efficacy of extended drug delivery.

Tolmetin sodium-loaded thermosensitive mucoadhesive liquid suppositories for rectal delivery; strategy to overcome oral delivery drawbacks

Tolmetin sodium (TS) is a nonsteroidal anti-inflammatory drug (NSAID) indicated for treatment of musculoskeletal issues. As other NSAID, TS displays a marked side effects on the gastro-intestinal (GI) tract after oral administration. Traditional solid suppositories can cause pain and discomfort for patients, may reach the end of the colon; consequently, the drug can undergo the first-pass effect. TS liquid suppository (TS-_LS) was developed to enhance patient compliance and rectal mucosal safety in high-risk patients receiving highly NSAID therapy. This work was conducted to optimize and evaluate Poloxamer P407/P188-based thermoresponsive TS-_LS by using mucoadhesive polymers such as methylcellulose (MC). TS-_LS was prepared by cold method and characterized their in vitro physicochemical properties as gelation temperature (GT), gel strength, bioadhesive properties, and in vitro release. The safety of the prepared suppository on rectum, stomach, and liver was evaluated histologically. Pharmacokinetic analyses were performed to compare rectal TS-_LS to orally Rhumtol^® capsules. The results showed that the optimized TS-_LS; composed of P407/P188/MC (21/9/0.5% w/w) displayed gelation at rectum temperature ∼32.90 °C, gel strength of 21.35 s and rectal retention force at the administration site of 24.25 × 10² dyne/cm². Moreover, TS-_LS did not cause any morphological damage to the rectal tissues. Pharmacokinetic parameters of optimized TS-_LS formulation revealed 4.6 fold increase in bioavailability as compared to Rhumtol^® capsules. Taken together, the results demonstrated that liquid suppository is a potential and physically safe rectal delivery carrier for improvement rectal bioavailability and in vivo safety of TS.

Ketorolac for Pain Control With Intrauterine Device Placement: A Randomized Controlled Trial

OBJECTIVE

To evaluate intramuscular ketorolac compared with placebo saline injection for pain control with intrauterine device (IUD) placement.

METHODS

We conducted a randomized, double-blind, placebo-controlled trial between July 2012 and March 2014. Patients received 30 mg ketorolac or placebo saline intramuscular injection 30 minutes before IUD placement. The primary outcome was pain with IUD placement on a 10-cm visual analog scale. Sample size was calculated to provide 80% power to show a 2.0-cm difference (α=0.05) in the primary outcome. Secondary outcomes included pain with study drug injection, speculum insertion, tenaculum placement, uterine sounding, and at 5 and 15 minutes after IUD placement.

RESULTS

A total of 67 women participated in the study, 33 in the ketorolac arm and 34 in the placebo arm. There were no differences in baseline demographics including age, body mass index, and race. There were no differences in median pain scores for IUD placement in the placebo compared with ketorolac groups (5.2 compared with 3.6 cm, P=.99). There was a decrease in median pain scores at 5 minutes (2.2 compared with 0.3 cm, P≤.001) and 15 minutes (1.6 compared with 0.1 cm, P≤.001) after IUD placement but no difference for all other time points. Nulliparous participants (n=16, eight per arm) had a decrease in pain scores with IUD placement (8.1 compared with 5.4 cm, P=.02). In this study, 22% of participants in the placebo group and 18% in the ketorolac group reported injection pain was as painful as IUD placement.

CONCLUSION

Ketorolac does not reduce pain with IUD placement but does reduce pain at 5 and 15 minutes after placement.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov; www.clinicaltrials.gov, NCT01664559.

LEVEL OF EVIDENCE

I.

Intramuscular ketorolac versus oral ibuprofen for pain relief in first-trimester surgical abortion: a randomized clinical trial

OBJECTIVE

Oral nonsteroidal antiinflammatory medications (NSAIDs) have been shown to reduce pain with first-trimester surgical abortion compared to placebo, but it is unclear if one NSAID is better than another. Some providers administer intramuscular ketorolac, though data regarding its efficacy in abortion are limited. This study was designed to compare oral ibuprofen to intramuscular ketorolac for pain management during first-trimester surgical abortion.

STUDY DESIGN

This was a randomized, double-blind, controlled trial. Women undergoing first-trimester surgical abortion with local anesthesia were randomized to preprocedural oral ibuprofen, 800 mg given 60-90 min preprocedure, or intramuscular ketorolac, 60 mg given 30-60 min preprocedure. The primary outcome was pain with uterine aspiration on a 21-point, 0-100, numerical rating scale. Secondary outcomes included pain with cervical dilation, postoperative pain and patient satisfaction.

RESULTS

Ninety-four women were enrolled; 47 were randomized to ibuprofen and 47 to ketorolac. The groups did not differ with regards to demographics, reproductive history or Depression Anxiety Stress Scale scores. Mean pain scores for suction curettage did not differ between groups (52.3 vs. 56.2, p=.53). There was also no difference in pain with cervical dilation (41.6 vs. 45.4, p=0.48) or postoperative pain (22.3 vs. 15.0 p=.076), though patients in the ketorolac group experienced significantly greater arm pain than those who received a placebo injection (30.4 vs. 15.6, p<.001). Satisfaction with pain control did not differ significantly by group.

CONCLUSIONS

Intramuscular ketorolac does not offer superior pain control compared to oral ibuprofen for first-trimester surgical abortion.

IMPLICATIONS

Intramuscular ketorolac does not offer superior pain control over oral ibuprofen during first-trimester surgical abortion, is more expensive and causes patients significant arm discomfort. Its use should therefore be reserved for patients who cannot tolerate oral NSAIDs.

Fatal adverse reaction to ketorolac tromethamine in asthmatic patient

A case of an asthmatic woman who collapsed within a few minutes after intramuscular ketorolac tromethamine (KT) injection is reported. Autopsy findings revealed anatomic evidence of a recent asthma attack. KT was found to be present in the blood at a concentration within the therapeutic range and consistent with the administered dose. Based on the timing of the collapse in relation to the KT administration, death was attributed to an adverse reaction to KT, resulting in acute bronchospasm and cardiac arrest, with asthma as an underlying contributing factor. In this case, asthma alone was not responsible for the death of the patient but only a contributing factor. Physicians have to be aware that in asthmatic patients bronchospasm can be induced by drugs among which aspirin or nonsteroidal anti-inflammatory drugs such as KT are the most common; therefore, death may have an iatrogenic cause. The paper also describes the pathogenic mechanism of an adverse reaction to such drugs and analytical methods for the isolation and detection of KT in postmortem blood.

Pain management in the ambulatory surgical population

Effective postoperative analgesia is a fundamental goal of patient management in the ambulatory surgery setting. There is a physiologic, psychological, and economic cost to unrelieved pain in the postoperative patient. Understanding (1) the individual experience of pain, (2) common barriers to effective pain management, (3) the concept of balanced analgesia, (4) the types and modes of action of various analgesics available to the ambulatory population, and (5) the importance of thorough and organized means of pain assessment will help the perianesthesia nurse optimize analgesia for the postoperative patient. Severe postoperative pain continues to be a problem in ambulatory patients once they are discharged to the home environment. This article looks at fundamental concepts in pain management and integrates these ideas into a comprehensive strategy for the management of postoperative pain in the ambulatory patient.

A review of preemptive analgesia

Postoperative pain, although frequently encountered, is often undertreated. A new method of treating postoperative pain is preemptive analgesia, which seeks to prevent or diminish pain before it is caused. A variety of drugs may be used and include nonsteriodal anti-inflammatory drugs, local anesthetics, opioids, and ketamine. They may be given before, during, and after surgery through the oral, intramuscular, intravenous, epidural, intrathecal, and intra-articular routes.