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Andre A, Benichou M, Dym H. Post-Procedure Analgesic Management. Dent Clin North Am 2024; 68:213-225. [PMID: 37951635 DOI: 10.1016/j.cden.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
During the development of multimodal pain management protocols, practitioners need to consider the potential risks each treatment modality inherently carries in order to prevent or diminish harmful outcomes. As an example, the part dentists played in the early stages of the opioid epidemic in the United States of America should serve as a cautionary account. By understanding the roots of this crisis, as practitioners we are better equipped to implement the novel analgesic agents available today to optimize post-operative pain control while minimizing any risk of addiction and harm to our communities. It is therefore critical that our colleagues understand the variety of accessible options for pain management to assure that our profession is able to seek adequate and sustainable relief for our post-operative patients. This article will go in depth to explain the analgesic tools practitioners can implement for an effective low-risk protocol, including a combination of NSAIDS and acetaminophen approach, using long-acting local anesthetics such as Exparel, pregabalin, gabapentin, ketamine, dexmedetomidine, and corticosteroids, and enhanced recovery after surgery protocols.
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Affiliation(s)
- Amanda Andre
- The Brooklyn Hospital Center, 121 Dekalb Avenue, Brooklyn, NY 11201, USA.
| | - Michael Benichou
- The Brooklyn Hospital Center, 121 Dekalb Avenue, Brooklyn, NY 11201, USA
| | - Harry Dym
- The Brooklyn Hospital Center, 121 Dekalb Avenue, Brooklyn, NY 11201, USA
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2
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Sonawane V, Ghosalkar J, Achrekar S, Joshi K. Ketorolac modulates Rac-1/HIF-1α/DDX3/β-catenin signalling via a tumor suppressor prostate apoptosis response-4 (Par-4) in renal cell carcinoma. Sci Rep 2023; 13:5659. [PMID: 37024613 PMCID: PMC10079967 DOI: 10.1038/s41598-023-32627-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 03/30/2023] [Indexed: 04/08/2023] Open
Abstract
Renal cell carcinoma (RCC) is the most difficult-to-treat form of kidney cancer with a median 5-year survival of 10% under metastatic setting. In RCC, although cytoreductive nephrectomy is common, approximately 20-30% of patients will develop recurrent cancer after surgery, which highlights the need for an effective therapy. Rho-GTPases viz, Rac-1 and Cdc42 are the central regulators of cancer cell migration and invasion and thus metastasis in multiple cancer types. Hence, we elucidated the role of Ketorolac, a modulator Rho-GTPases against RCC through potentiation of tumor suppressor Par-4. The effect of Ketorolac alone and in combination on proliferation, apoptosis, cell-cycle progression, migration, tumor inhibition and their related markers were studied. Moreover, Ketorolac's impact on metastasis by influencing Rac-1/HIF-1α/DDX3/β-catenin signalling was studied with respect to its ability to modulate the expression of tumor suppressor Par-4, and this mechanism was confirmed by siRNA knockdown studies. Ketorolac induced cytotoxicity in a panel of renal cells including patient derived tumor cells with IC50 2.8 to 9.02 mM and 0.28 to 3.8 mM in monolayer and anchorage independent clonogenic assays respectively. Ketorolac caused significant down regulation of proliferation (Ki-67, Cyclin D1, pRB and DDX3), migration/invasion (Rac-1, Cdc42, and Tiam1), and angiogenesis (HIF-1α and VEGF) markers as studied by gene and protein expression. Moreover, it caused a significant upregulation of tumor suppressor Par-4 known to be downregulated in RCC. This mechanism was further confirmed by using siRNA knockdown studies where we could demonstrate a negative relation between the expression of Par-4 and Rac-1/Cdc42. Importantly, Ketorolac alone and in combination with Sunitinib showed tumor growth inhibition (TGI) of 73% and 86% respectively in xenograft model. This anti-tumor activity was further corroborated by down regulation of Rac-1/Cdc42/HIF-1α/DDX3/β-catenin signalling. This is the first report which implicates the role of Ketorolac against RCC by acting as a small molecule secretagogue causing upregulation of Par-4 in autocrine and paracrine manner. Consequently, these findings suggest that Par-4 can serve as a valuable therapeutic target and a prognostic marker for the treatment of RCC.
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Affiliation(s)
- Vinay Sonawane
- Cell Biology Division, Cipla Ltd., LBS Marg, Vikhroli West, Mumbai, 400083, India
| | - Jeevan Ghosalkar
- Cell Biology Division, Cipla Ltd., LBS Marg, Vikhroli West, Mumbai, 400083, India
| | - Swati Achrekar
- Cell Biology Division, Cipla Ltd., LBS Marg, Vikhroli West, Mumbai, 400083, India
| | - Kalpana Joshi
- Cell Biology Division, Cipla Ltd., LBS Marg, Vikhroli West, Mumbai, 400083, India.
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3
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Sohail R, Mathew M, Patel KK, Reddy SA, Haider Z, Naria M, Habib A, Abdin ZU, Razzaq Chaudhry W, Akbar A. Effects of Non-steroidal Anti-inflammatory Drugs (NSAIDs) and Gastroprotective NSAIDs on the Gastrointestinal Tract: A Narrative Review. Cureus 2023; 15:e37080. [PMID: 37153279 PMCID: PMC10156439 DOI: 10.7759/cureus.37080] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2023] [Indexed: 04/05/2023] Open
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used for their anti-inflammatory, antipyretic, and analgesic properties. However, their use is often associated with gastrointestinal tract (GIT) side effects due to the inhibition of both cyclooxygenase (COX)-1 and COX-2 enzymes, leading to a decrease in gastroprotective prostaglandins (PG). To minimize these adverse effects, various approaches have been explored, including selective COX-2 inhibitors, NO-NSAIDs (nitric oxide-releasing NSAIDs), and dual COX/LOX (lipoxygenase) NSAIDs. However, the effects of these gastroprotective NSAIDs on the GIT and their efficacy remains uncertain. This review aims to provide an overview of the current understanding of the effects of traditional NSAIDs and gastroprotective NSAIDs on GIT. We discuss the underlying mechanisms of GIT damage caused by NSAIDs, including mucosal injury, ulceration, and bleeding, and the potential of gastroprotective NSAIDs to mitigate these effects. We also summarize recent studies on the efficacy and safety of various gastroprotective NSAIDs and highlight the limitations and challenges of these approaches. The review concludes with recommendations for future research in this field.
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Affiliation(s)
- Rohab Sohail
- Internal Medicine, Quaid-e-Azam Medical College, Bahawalpur, PAK
| | - Midhun Mathew
- Department of Internal Medicine, Pennsylvania Hospital, Philadelphia, USA
| | - Khushbu K Patel
- Internal Medicine, Index Medical College Hospital & Research Center, Indore, IND
| | - Srija A Reddy
- Internal Medicine, Malla Reddy Institute of Medical Sciences, Hyderabad, IND
| | - Zaroon Haider
- Internal Medicine, Combined Military Hospital (CMH) Lahore Medical College and Institute of Dentistry, Lahore, PAK
| | - Mansi Naria
- Internal Medicine, American University of Barbados, Bridgetown, BRB
| | - Ayesha Habib
- Internal Medicine, Punjab Medical College, Faisalabad, PAK
| | - Zain U Abdin
- Medicine, District Head Quarter Hospital, Faisalabad, PAK
| | | | - Anum Akbar
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, USA
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4
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Tsu E, Mathew P, Ernst E, Vesel T. Intravenous Ketorolac Infusion for Intractable Pleuritic Pain Secondary to Metastatic Epithelioid Hemangioendothelioma. J Palliat Med 2021; 24:1744-1748. [PMID: 34297626 DOI: 10.1089/jpm.2021.0277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Epithelioid hemangioendothelioma (EHE) patients can experience severe pain. Nonsteroidal anti-inflammatory drugs, including ketorolac tromethamine, can effectively treat cancer-related pain, provide an opioid-sparing effect, and may be particularly effective for EHE pain. There are limited data describing prolonged (>5 days) continuous intravenous (IV) ketorolac infusion for cancer-related pain and no data on its use in EHE. Case Description: A 67-year-old woman with metastatic hepatic EHE suffered from chronic intractable pleuritic pain unresponsive to trials of nonopioid, opioid, adjuvant medications, and nonpharmacological interventions. In the hospital, continuous IV ketorolac infusion at 3.8 mg/hour (91.2 mg/day) effectively managed pain. With thorough monitoring, the patient was discharged on continuous IV ketorolac infusion at 3 mg/hour (72 mg/day). Infusion continued for 79 days without clinical or laboratory evidence of ketorolac toxicity. Conclusion: Ketorolac tromethamine as a long-term infusion is a potentially viable analgesic for patients with intractable EHE-related pain unresponsive to standard therapies.
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Affiliation(s)
- Eric Tsu
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Paul Mathew
- Division of Hematology/Oncology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Emma Ernst
- Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Tamara Vesel
- Division of Palliative Care, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
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Chuckpaiwong B, Harnroongroj T, Sirivanasandha B, Tharmviboonsri T. Local Ketorolac Injection vs Popliteal Sciatic Nerve Blockade as an Adjuvant to a Spinal Block in Hindfoot Arthrodesis. Foot Ankle Int 2021; 42:570-574. [PMID: 33334174 DOI: 10.1177/1071100720972666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Popliteal nerve blocks reduce pain and markedly improve postoperative outcomes during foot and ankle surgery; however, several potential complications may arise from nerve block procedures. The purpose of this study was to investigate local infiltration analgesia with ketorolac as a convenient alternative for pain relief. METHODS A total of 80 patients scheduled for hindfoot arthrodesis were randomly allocated to one of 2 anesthetic groups: a spinal block augmented with either a popliteal nerve block (n = 40) or local ketorolac and Marcaine infiltration (n = 40). Clinical assessment included postoperative visual analog scale (VAS) pain scores at 4, 8, 12, 24, and 48 hours, total morphine consumption, time to incision (time in operating room to incision), operative time, length of hospital stay, and complications. RESULTS Despite similar morphine consumption between groups (P = .28), VAS scores were significantly lower at 24 hours (1.6 ± 2.2 cm vs 2.7 ± 3.0 cm, P = .01) and 48 hours (0.2 ± 0.7 cm vs 1.0 ± 1.5 cm, P < .01) after surgery using local ketorolac injection. Although time from entry into the operating room to incision was also reduced after local ketorolac injection (19.0 ± 5.3 minutes vs 31.4 ± 14.6 minutes, P < .001), the length of operative time (P = .38), hospital stay (P = .43), and number of complications (P = .24) were similar between groups. CONCLUSION Ketorolac local injection provided effective pain control in hindfoot arthrodesis and markedly reduced VAS pain scores up to 48 hours after surgery compared with popliteal nerve block. In addition, ketorolac local injection also reduced time in the operating room compared with popliteal nerve blockade. LEVEL OF EVIDENCE Level 1, randomized controlled trial.
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Affiliation(s)
- Bavornrit Chuckpaiwong
- Department of Orthopaedic Surgery and Rehabilitation, Faculty of Medicine, Siririaj Hospital Mahidol University, Bangkok, Thailand.,College of Sports Science and Technology, Mahidol University, Nakornpathom, Thailand
| | - Thos Harnroongroj
- Department of Orthopaedic Surgery and Rehabilitation, Faculty of Medicine, Siririaj Hospital Mahidol University, Bangkok, Thailand
| | - Busara Sirivanasandha
- Department of Anesthesiology, Faculty of Medicine, Siririaj Hospital Mahidol University, Bangkok, Thailand
| | - Theerawoot Tharmviboonsri
- Department of Orthopaedic Surgery and Rehabilitation, Faculty of Medicine, Siririaj Hospital Mahidol University, Bangkok, Thailand
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Madrigal DA, Escalante CH, Gutiérrez-Rebolledo GA, Cristobal-Luna JM, Gómez-García O, Hernández-Benitez RI, Esquivel-Campos AL, Pérez-Gutiérrez S, Chamorro-Cevallos GA, Delgado F, Tamariz J. Synthesis and highly potent anti-inflammatory activity of licofelone- and ketorolac-based 1-arylpyrrolizin-3-ones. Bioorg Med Chem 2019; 27:115053. [DOI: 10.1016/j.bmc.2019.115053] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 08/18/2019] [Accepted: 08/19/2019] [Indexed: 02/05/2023]
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Wagner-Kovacec J, Povalej-Brzan P, Mekis D. Efficacy of continuous in-wound infusion of levobupivacaine and ketorolac for post-caesarean section analgesia: a prospective, randomised, double-blind, placebo-controlled trial. BMC Anesthesiol 2018; 18:165. [PMID: 30414609 PMCID: PMC6234771 DOI: 10.1186/s12871-018-0609-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 10/05/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In-wound catheters for infusion of local anaesthetic for post-caesarean section analgesia are well tolerated in parturients. Few studies have examined continuous in-wound infusion of a combination of local anaesthetic and non-steroidal anti-inflammatory drug for post-caesarean section analgesia. This single centre study evaluated post-operative analgesic efficacy and piritramide-sparing effects of continuous in-wound infusion of either local anaesthetic or non-steroidal anti-inflammatory agent, or the combination of both, versus saline placebo, when added to systemic analgesia with paracetamol. METHODS After National Ethical Board approval, 59 pregnant women scheduled for non-emergency caesarean section were included in this prospective, randomised, double-blind, placebo-controlled study. The parturients received spinal anaesthesia with levobupivacaine and fentanyl. Post-operative analgesia to 48 h included paracetamol 1000 mg intravenously every 6 h, with the studied agents as in-wound infusions. Rescue analgesia with piritramide was available as needed, titrated to 2 mg intravenously. Four groups were compared, using a subcutaneous multi-holed catheter connected to an elastomeric pump running at 5 mL/h over 48 h. The different in-wound infusions were: levobupivacaine 0.25% alone; ketorolac tromethamine 0.08% alone; levobupivacaine 0.25% plus ketorolac tromethamine 0.08%; or saline placebo. The primary outcome was total rescue piritramide used at 24 h and 48 h post-operatively, under maintained optimal post-caesarean section analgesia. RESULTS Compared to placebo in-wound infusions, ketorolac alone and levobupivacaine plus ketorolac in-wound infusions both significantly reduced post-operative piritramide consumption at 24 h (p = 0.003; p < 0.001, respectively) and 48 h (p = 0.001; p < 0.001). Compared to levobupivacaine, levobupivacaine plus ketorolac significantly reduced post-operative piritramide consumption at 24 h (p = 0.015) and 48 h (p = 0.021). For levobupivacaine versus ketorolac, no significant differences were seen for post-operative piritramide consumption at 24 h and 48 h (p = 0.141; p = 0.054). CONCLUSION Continuous in-wound infusion with levobupivacaine plus ketorolac provides greater opioid-sparing effects than continuous in-wound infusion with levobupivacaine alone. TRIAL REGISTRATION German Clinical Trials Register: retrospectively registered on 30 July, 2014, DRKS 00006559 .
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Affiliation(s)
- Jozica Wagner-Kovacec
- Department of Anaesthesiology, Intensive Care and Pain Management, University Medical Centre Maribor, Ljubljanska ulica 5, 2000, Maribor, Slovenia.
| | - Petra Povalej-Brzan
- Faculty for Health Sciences, University of Maribor, Žitna ulica 15, 2000, Maribor, Slovenia.,Medical Faculty, University of Maribor, Taborska ulica 8, 2000, Maribor, Slovenia.,Faculty of Electrical Engineering and Computer Science, University of Maribor, Koroška cesta 46, 2000, Maribor, Slovenia
| | - Dusan Mekis
- Department of Anaesthesiology, Intensive Care and Pain Management, University Medical Centre Maribor, Ljubljanska ulica 5, 2000, Maribor, Slovenia.,Faculty for Health Sciences, University of Maribor, Žitna ulica 15, 2000, Maribor, Slovenia.,Medical Faculty, University of Maribor, Taborska ulica 8, 2000, Maribor, Slovenia.,Department for Medical Research, University Medical Centre Maribor, Ljubljanska ulica 5, 2000, Maribor, Slovenia
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8
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Vadivelu N, Chang D, Helander EM, Bordelon GJ, Kai A, Kaye AD, Hsu D, Bang D, Julka I. Ketorolac, Oxymorphone, Tapentadol, and Tramadol: A Comprehensive Review. Anesthesiol Clin 2017; 35:e1-e20. [PMID: 28526155 DOI: 10.1016/j.anclin.2017.01.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Pain remains a tremendous burden on patients and for the health care system, with uncontrolled pain being the leading cause of disability in this country. There are a variety of medications that can be used in the treatment of pain, including ketorolac, oxymorphone, tapentadol, and tramadol. Depending on the clinical situation, these drugs can be used as monotherapy or in conjunction with other types of medications in a multimodal approach. A strong appreciation of pharmacologic properties of these agents and potential side effects is warranted for clinicians.
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Affiliation(s)
- Nalini Vadivelu
- Department of Anesthesiology, Yale University School of Medicine, 333 Cedar Street, PO Box 208051, New Haven, CT 06520-8051, USA.
| | - Daniel Chang
- Department of Anesthesiology, Yale University School of Medicine, 333 Cedar Street, PO Box 208051, New Haven, CT 06520-8051, USA
| | - Erik M Helander
- Department of Anesthesiology, Louisiana State University Health Sciences Center, 1542 Tulane Avenue, New Orleans, LA 70112, USA
| | - Gregory J Bordelon
- Department of Anesthesiology, Louisiana State University Health Sciences Center, 1542 Tulane Avenue, New Orleans, LA 70112, USA
| | - Alice Kai
- Department of Anesthesiology, Yale University School of Medicine, 333 Cedar Street, PO Box 208051, New Haven, CT 06520-8051, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, 1542 Tulane Avenue, New Orleans, LA 70112, USA
| | - Dora Hsu
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Ronald Reagan UCLA Medical Center, 757 Westwood Plaza, Suite 3325, Los Angeles, CA 90095-7403, USA
| | - Daniel Bang
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Ronald Reagan UCLA Medical Center, 757 Westwood Plaza, Suite 3325, Los Angeles, CA 90095-7403, USA
| | - Inderjeet Julka
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Ronald Reagan UCLA Medical Center, 757 Westwood Plaza, Suite 3325, Los Angeles, CA 90095-7403, USA
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Burdick M, Mamelok R, Hurliman M, Dupuis M, Xie Y, Grenier J, Sheldon C, Gartner M, Noymer P. Comparison of the Pharmacokinetics of Ketorolac Tromethamine After Continuous Subcutaneous Infusion and Repeat Intramuscular Bolus Injections in Healthy Adult Subjects. Clin Pharmacol Drug Dev 2017; 6:343-349. [PMID: 27739232 DOI: 10.1002/cpdd.319] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 10/05/2016] [Indexed: 11/10/2022]
Abstract
Ketorolac tromethamine is a nonsteroidal anti-inflammatory drug that exhibits analgesic activity with no sedative or anxiolytic properties. Twelve healthy male subjects were enrolled in a study to receive either of 2 treatments over 2 periods in an open-label, randomized, 2-way crossover design: (A) 120 mg of ketorolac tromethamine administered as a continuous subcutaneous infusion over a 24-hour period; or (B) an identical total daily dose administered as 4 intramuscular bolus injections of 30 mg each given every 6 hours (current labeled treatment regimen). The pharmacokinetic and safety profiles were evaluated for both treatments. Both modes of administration have similar values for area under the curve (AUC) and half-life (t1/2 ), suggesting that continuous subcutaneous infusion and repeated intramuscular bolus injections have similar bioavailability. The peak plasma concentration (Cmax ) was 40% lower when ketorolac was administered as a continuous subcutaneous infusion compared with repeat intramuscular bolus injections. The concentration at steady-state (Css ) for continuous subcutaneous infusion was between the Cmax and Ctrough values obtained following the 4 intramuscular injections. Both treatment arms were well tolerated.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Peter Noymer
- SteadyMed Therapeutics, Inc., San Ramon, CA, USA
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