Gastrointestinal complications associated with intramuscular ketorolac tromethamine therapy in the elderly

Ketorolac use for postoperative pain management following lumbar decompression surgery: a prospective, randomized, double-blinded, placebo-controlled trial

STUDY DESIGN

Prospective randomized double-blind placebo-controlled study.

OBJECTIVE

The objective of this study was to assess the efficacy of Ketorolac in reducing postoperative pain and morphine requirements following primary multilevel lumbar decompression surgery.

SUMMARY OF BACKGROUND DATA

The use of opioid medications following surgical interventions can be complicated by related side effects such as respiratory depression, somnolence, urinary retention, and delayed time to oral intake. The use of Ketorolac, a potent nonopioid, nonsteroidal anti-inflammatory drug, is an attractive alternative to morphine as many of the opioid-related side effects can be avoided.

METHODS

After Institutional Review Board approval, 25 patients who underwent a primary multilevel lumbar decompression procedure were randomly assigned to receive either Ketorolac or placebo in a double-blinded fashion. After surgery, all patients were allowed to receive intravenous morphine on an as needed basis. Morphine requirements were then recorded immediately postoperative, at 6, 12, and at 24 hours postoperative. A patient's overall hospital course morphine requirement was also assessed. Patient postoperative pain levels were determined using the Visual Analog Pain Scale and were documented at 4, 8, 12, 16, 24, and 36 hours postoperative.

RESULTS

There were no significant differences in available patient demographics, intraoperative blood loss, or postoperative Hemovac drain output between study groups. Morphine equivalent requirements were significantly less at all predetermined time points in addition to the overall hospital morphine requirement in patients randomized to receive Ketorolac. Visual Analog Pain Scores were significantly lower in patients randomized to receive Ketorolac immediately postoperative in addition to 4, 12, and 16 hours postoperative. There were no identifiable postoperative complications associated with the use of Ketorolac. CONCLUSION.: Intravenous Ketorolac seems to be a safe and effective analgesic agent following multilevel lumbar decompressive laminectomy. Patients can expect lower morphine requirements and better pain scores throughout their postoperative course.

Over-the-counter analgesics in older adults: a call for improved labelling and consumer education

The use of analgesics increases with age and on any given day 20-30% of older adults take an analgesic medication. Over-the-counter (OTC) analgesics are generally well tolerated and effective when taken for brief periods of time and at recommended dosages. However, their long-term use, use at inappropriately high doses, or use by persons with contraindications may result in adverse effects, including gastrointestinal haemorrhage, cardiovascular toxicity, renal toxicity and hepatotoxicity. Many OTC drugs are also available through a prescription, for a broader range of indications and for longer durations of use and wider dose ranges, under the assumption that healthcare providers will help patients make safe choices about analgesics. Safe and effective use of medications is one of the greatest challenges faced by healthcare providers in medicine. More than 60% of people cannot identify the active ingredient in their brand of pain reliever. Additionally, about 40% of Americans believe that OTC drugs are too weak to cause any real harm. As a result of a recent US FDA policy, the conversion of prescription to OTC medications will result in a 50% increase of OTC medications. To reduce the risks of potential adverse effects from OTC drug therapy in older adults, we propose that the use of analgesics will be enhanced through the use of patient and healthcare provider education, as well as improved labelling of OTC analgesics. Improved labelling of OTC analgesics may help consumers distinguish common analgesic ingredients in a wide variety of preparations and facilitate informed decisions concerning the use of OTC drugs.

Intravenous analgesia

Pain and its treatment are known to have adverse effects on the organism, including deterioration in myocardial, diaphragmatic, and small bowel function. The provision of adequate intravenous analgesia, and the choice of agent, can ameliorate or exacerbate these manifestations of the stress response. The choice of agent, opioid or non-opioid, has in some respects become more difficult as more information has become available regarding the merits and adverse effects of each. Increased awareness of the frequency of hypoxemia secondary to the opioids' ability to cause an obstructive sleep apnea picture, and the cost efficiency of ketorolac through a reduction in opioid toxicity, contrast with recent studies which suggest that the gastrotoxic and nephrotoxic effects of ketorolac may occur earlier than previously suspected. The suitability of using the dissociative anesthetic agent ketamine in critically ill patients remains to be proven. Ketamine provides intense analgesia at subanesthetic doses. Its centrally mediated sympathomimetic action encourages hemodynamic stability, and it is relatively devoid of respiratory depressant activity. Increasing experience with ketamine outside the operating room has resulted in its successful use in cases of severe bronchospasm and status epilepticus.

Clinical implications of ketorolac for postoperative analgesia

Ketorolac is the only nonsteroidal anti-inflammatory drug (NSAID) in widespread clinical use that is available in an injectable form. Though similar to aspirin and ibuprofen, it is much more potent. In fact, it is potent enough to be useful for postsurgical pain either alone or in combination with other pain relief strategies. For many types of pain, ketorolac is comparable in potency with opioids though the mechanism by which it relieves pain is significantly different. Ketorolac has a much longer duration than morphine or meperidine but has a slower onset. Though we sometimes perceive NSAIDs as almost harmless, ketorolac is a potent drug and, like other potent drugs, has the potential to produce potent adverse effects including organ disfunction and allergic reaction. Risk factors for these adverse effects are well understood, allowing the clinician to plan the ketorolac use safely. Well planned patient selection and ketorolac administration can improve patient care by reducing opioid side effects and improving analgesia while speeding patient recovery and PACU discharge times.

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.