Risk factors for low back pain after iliac vein stenting for non-thrombotic iliac vein lesions

OBJECTIVE

Iliac vein stenting is an option being explored to treat chronic venous insufficiency. We have noted that our most common postoperative complication is low back pain after stent placement, which is occasionally quite severe. We wanted to investigate risk factors that are involved in this phenomenon and identify potentially modifiable factors.

METHODS

Patients who failed 3 months of conservative therapy had iliac vein interrogation performed. We limited the scope of this database to non-thrombotic iliac vein lesions treated in the office in which Wallstents were placed. Data were collected from September 2012 to August 2020 for 2308 consecutive outpatients who underwent 3747 procedures. Before August 2016, patients received pre-procedure oral valium (n = 2679) and thereafter, patients received intravenous (IV) sedation (n = 1068). A pain score, on a Likert scale ranging from 0 to 10, was assessed within 1 hour postoperatively. We analyzed the medications administered and correlated them with pain scores.

RESULTS

The average of all the pain scores was 0.86 (range, 0-10; standard deviation [SD], 2.00). Age had a slight inverse effect on pain scores (r = -0.12; P < .00001). Presenting signs (based upon CEAP) (P = .11) and body mass index (P = .88) did not have a significant effect on pain scores. Average pain score for females (0.96) was slightly higher than for males (0.70), with P < .0001. Average pain score for procedures on the right side (0.67) was lower than for procedures on the left side (1.01), with P < .0001. Average pain score for patients who received IV sedation (mean, 0.68; SD, 1.58) was lower than that for those who did not (mean, 0.93; SD, 2.15), with P = .0004. When using a single agent, propofol was associated with the lowest pain scores (P < .0001). Toradol displayed a dose-dependent effect on pain score (P < .0001). The best combination of agents for pain control was propofol and toradol together.

CONCLUSIONS

Overall, the vast majority of pain scores were low. Factors that were associated with lower pain scores were older age, male sex, procedures on the right side, and IV sedation, in particular with the use of propofol. These data may help us better target patients anticipated to have high pain scores and suggest the preferential use of propofol and toradol.

Preformulation-Assisted Design of Ketorolac Tromethamine for Effective Ophthalmic Delivery

Background: The eye is a highly protected organ from ocularly administered drugs; drug- and formulation-related factors contribute significantly to ocular bioavailability. There has been a growing interest in using nonsteroidal anti-inflammatory drugs in ophthalmology for treating postoperative pain, inflammation, and seasonal allergic conjunctivitis. A preformulation-assisted design boosts efficacy and reduces dose requirements. Methods: This work aims to study the preformulation characteristics of ketorolac tromethamine to improve ocular performance and future formulation development through developing an high-performance liquid chromatography (HPLC) stability-indicating assay, forced degradation under stress conditions, solubility, as well as partition and distribution coefficient measurements. An isocratic HPLC with diode array detector method was developed and validated. Accelerated degradation under different stressors (acid, alkali, heat, and oxidative) was studied. In addition, solubility, partition, and distribution were investigated at different pHs of 3.5-7.4. Results: The results indicated that the developed HPLC method was simple, rapid (retention time ≃3 min), sensitive, selective, robust, and stability indicating. The drug seems more chemically sensitive to acid degradation (∼30% and 40% of the drug was degraded under 0.1 M and 1 M HCl at 60°C for 24 h, respectively). Another significant degradation was recorded in the following order: Oxidative > alkali > heat (phosphate-buffered saline) > heat (distilled water). Being a weak ionizable drug, both water and lipid solubility, as measured through partition coefficients, it demonstrated pH-dependency. Conclusion: For the optimum balance of water and lipid solubility required for penetration through the lipophilic corneal epithelial barrier, ketorolac eye drops would be better formulated between pH 5.5 and 6.6 than being formulated at the physiological fluid pH 7.4, where the drug is extremely hydrophilic and less permeable.

UV spectrophotometric methods for simultaneous determination of ketorolac tromethamine and olopatadine hydrochloride: Application of multiple standard addition for assay of ophthalmic solution

Ophthalmic preparations that contain ketorolac tromethamine (KET) and olopatadine HCl (OLO) are used to relieve seasonal allergies and allergic conjunctivitis. Simultaneous quantification of KET and OLO was held by validated and simple spectrophotometric methods. KET was determined directly from the fundamental UV absorption spectra (at 323 nm), while OLO was determined after performing either dual wavelength or ratio derivative methods. The first method was based on measuring the absorbance difference (ΔA) between 243 and 291 nm, while the second depended on generating first derivative ratio spectra using 3.0 µg/mL KET as a divisor and measuring OLO responses at 234 nm (minima). Multiple standard addition method was applied to enable the determination of OLO which is considered as the weakly absorbing species as well as the minor component in a challenging dosage form ratio (4:1). The linearity ranges of the developed methods were 3-12 μg/mL and 4-40 μg/mL for KET and OLO, respectively. Simultaneous determination of both drugs was successfully implemented to lab prepared eye drops that contain KET, OLO and benzalkonium chloride as an inactive ingredient. Greenness assessment indicates minimal impact on environment. The developed methods determined the cited drugs with % recovery ± SD of 99.63 ± 0.01 for KET, 100.90 ± 0.02 and 100.31 ± 0.01 for OLO using dual wavelength and first derivative ratio methods, respectively. Using F-test and t-test at confidence level %95 to compare between the results of the presented methods and a reported method show no significant difference which allows precise, accurate, rapid, and simple quantification of quality control samples that contain KET and OLO.

Effect of Ketorolac Tromethamine Combined With Remifentanil on Reducing Complications During the General Anesthesia Emergence

PURPOSE

To observe the effect of ketorolac tromethamine combined with remifentanil in sedation and analgesia during general anesthesia emergence and reducing general anesthesia complications.

DESIGN

This is an experimental design.

METHODS

A total of 90 patients who underwent partial or total thyroidectomy in our hospital were selected and randomly divided into three groups with 30 cases in each group. Routine general anesthesia combined with endotracheal intubation was given for general anesthesia, and different treatments were administered when the skin was sutured. Group K: intravenous injection of ketorolac tromethamine 0.9 mg/kg, intravenous injection of normal saline 10 mL/h by micropump until awakening and extubation; R group: intravenous injection of normal saline 2 mL, micropump intravenous injection of remifentanil 0.1 mcg/kg/min until awakening and extubation; KR group: intravenous injection of ketorolac tromethamine 0.5 mg/kg, micropump intravenous injection remifentanil 0.05 mcg/kg/min until awakening and extubation. After the operation, all patients entered the postanesthesia care unit (PACU) for recovery, extubation, scoring. The incidence and condition of various complications were counted.

FINDINGS

There was no significant difference in the general information or operation duration of the patients (P > .05). The types of general anesthesia induction drugs in each group were the same, and there was no significant difference in drug measurement (P > .05). The visual analogue scales of KR group were: 2.2 ± 0.6(T0) and 2.4 ± 0.9(T1), the Self-Rating Anxiety Scale scores of the KR groups were: 4.1 ± 0.6(T0), 3.7 ± 0.4(T1). Compared with the KR group, the visual analogue scale and Self-Rating Anxiety Scale scores of the K and R groups at T0 and T1 were increased (P < .05); the visual analogue scale and Self-Rating Anxiety Scale scores of the K and R groups at T0 and T1 were not significantly different (P > .05); at T2, there was no significant difference in visual analogue scale and Self-Rating Anxiety Scale scores among the three groups (P > .05). There was no significant difference in extubation time or PACU transfer time among the three groups (P > .05). The incidence of adverse reactions in KR group were: 3.3% (nausea), 3.3% (vomit), 0 (coughing and drowsiness). Compared with the KR group, the incidence of adverse reactions was higher in the K and R groups.

CONCLUSIONS

Ketorolac tromethamine combined with remifentanil can effectively relieve pain and sedation during general anesthesia recovery and reduce the incidence of complications related to general anesthesia recovery. At the same time, the application of ketorolac tromethamine can reduce the dosage of remifentanil and inhibit the occurrence of adverse reactions when used alone.

Efficacy of Oral Toradol (Ketorolac) Compared to Oral Tramadol as a Preemptive Analgesic in Impacted Third Molar Surgery

OBJECTIVE

To compare ketorolac with Tramadol as a preemptive analgesic in impacted third molar surgery in terms of mean pain score, mean time of first analgesic and mean total analgesic consumption postoperatively.

STUDY DESIGN

Experimental study. Place and Duration of the Study: Department of Oral and Maxillofacial Surgery, Islamic International Dental Hospital, (IIDH) Riphah International University, Islamabad, from March 2018 to March 2020.

METHODOLOGY

Ninety-four patients, aged 18-45 years with impacted third molars were divided into two groups. Preoperatively oral tramadol 50 mg was given in group A and oral ketorolac 10 mg was given in group B. Pain score was measured 3 hours postoperatively, using the visual analogue scale (VAS), the time was noted for first analgesic consumption in hours and total consumption of analgesics.

RESULTS

The mean postoperative pain was measured for both groups. Pain was significantly less in Group B. The mean pain score was 4.02+1.20 in group A and 3.42+1.08 in group B measured at 3 hours postoperatively (p=0.02). The mean time interval for 1st postoperative analgesic was 2.90+1.24 hours in group A and 3.61+1.02 in group B (p=0.007). The mean total analgesic consumption was 3.75+1.27 grams in Group A and 2.27+1.74 grams min Group B (p=0.006).

CONCLUSION

Preemptive Ketorolac has a more prolonged analgesic effect as compared to tramadol.

KEY WORDS

Preemptive analgesia, Tramadol, Ketorolac, Pain score, Third molar surgery.

Stability and compatibility of admixtures containing bupivacaine hydrochloride and ketorolac tromethamine for parenteral use

OBJECTIVE

Bupivacaine hydrochloride (BH) and ketorolac tromethamine (KT) are commonly used in parenteral admixtures to manage postoperative pain. However, stability and compatibility data for these admixtures applicable to current practice are limited, posing the patient to potential risk.

METHODS

The stability of BH/KT admixtures in commonly used parenteral fluids was studied in Eppendorf tubes and glass vials at ambient room temperature using a newly developed and validated stability-indicating high-performance liquid chromatography (HPLC) method capable of the simultaneous quantification of both drugs. The chemical compatibility of BH/KT was assessed using Fourier transform infrared spectroscopy (FTIR) and thermal analysis. Additionally, the validity of the developed HPLC method for the quantification of BH/KT in human plasma was evaluated.

RESULTS

BH and KT demonstrated <10% loss of their initial concentrations when prepared in Ringer, normal saline or dextrose solution at ambient temperature for up to 4 weeks. FTIR and thermal analysis demonstrated mild intermolecular interactions between BH and KT in solution, with no evidence of incompatibility. The developed HPLC method demonstrated satisfactory accuracy and precision for the simultaneous quantification of BH and KT in human plasma over the range of 0.2-3.2 µg·mL-1.

CONCLUSION

BH/KT parenteral admixtures are chemically stable for a period of 4 weeks when stored at room temperature. The stability-indicating HPLC method is valid for BH/KT simultaneous determination in human plasma, facilitating pharmacokinetics studies.

Construction of multifunctional NH2-UiO-66 metal organic framework: sensing and photocatalytic degradation of ketorolac tromethamine and tetracycline in aqueous medium

Existence of pharmaceutical residues in water has endangered environmental pollution worldwide, which makes it ineludible to develop prospective bifunctional materials which not only possess excellent fluorescence behaviour to monitor pharmaceuticals but also exhibit simultaneous photocatalytic removal efficiency. Strengthened by functionalized metal organic framework (MOF) materials, we present here an amine functionalized zirconium-based MOF NH₂-UiO-66 which has been successfully synthesized using solvothermal approach. The as prepared MOF was subjected to numerous structural, morphological and compositional characterizations. Interestingly, featured by the excellent fluorescent intensity of MOF modulated by LMCT effect, NH₂-UiO-66 was screened to detect pharmaceutical compounds with KTC and TC in aqueous solution. The prepared functionalized MOF showcased excellent sensing platform with magnificent response range (0‒3 µM), lower limit of detection (160 nM; KTC and 140 nM; TC), excellent selectivity and influential anti-interference capability. More importantly, the practical utility of the proposed sensor was further explored for the determination of pharmaceutical drugs in real water samples with suitable recoveries. Simultaneously, the synthesized MOF also exhibited high photocatalytic efficiency towards the removal of KTC and TC under solar light irradiation. The degradation efficiency for KTC and TC was found to be 68.3% and 71.8% within 60 and 280 min of solar light, respectively. Moreover, excellent recyclability was demonstrated by the current synthesized system over five cycles. Overall, this study presents a feasible route for the utilization of functionalized MOFs as potential dual functional materials towards the simultaneous detection and degradation of specific pharmaceuticals from aqueous medium.

Effects of topical instillation of 0.1% diclofenac sodium, 0.5% ketorolac tromethamine, and 0.03% flurbiprofen sodium on corneal sensitivity in ophthalmologically normal cats

OBJECTIVE

To investigate the effects of short-term and prolonged topical instillation of 0.1% diclofenac sodium, 0.5% ketorolac tromethamine, and 0.03% flurbiprofen sodium on corneal sensitivity (CS) in ophthalmologically normal cats.

ANIMALS

12 healthy adult domestic shorthair cats.

PROCEDURES

In the first of 2 study phases, each cat received 0.1% diclofenac sodium, 0.5% ketorolac tromethamine, 0.03% flurbiprofen sodium, and saline (0.9% NaCl; control) solutions (1 drop [0.05 mL]/eye, q 5 min for 5 treatments) in a randomized order with a 2-day washout period between treatments. For each cat, an esthesiometer was used to measure CS before treatment initiation (baseline) and at 15, 30, 45, and 60 minutes after the last dose. There was a 2-day washout period between phases. The second phase was similar to the first, except each treatment was administered at a dosage of 1 drop/eye, twice daily for 5 days and CS was measured before treatment initiation and at 15 minutes and 24 and 48 hours after the last dose. The Friedman test was used to evaluate change in CS over time.

RESULTS

None of the 4 treatments had a significant effect on CS over time in either study phase.

CONCLUSIONS AND CLINICAL RELEVANCE

Results indicated that neither short-term nor prolonged topical instillation of 3 NSAID ophthalmic solutions had any effect on the CS of healthy cats. Given potential differences in cyclooxygenase expression between healthy and diseased eyes, further investigation of the effects of topical NSAID instillation in the eyes of cats with ocular surface inflammation is warranted.

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.

Interventions for relieving pain associated with panretinal photocoagulation: a prospective randomized trial

PURPOSE

To evaluate the efficacy of pain relief by oral diazepam, acetaminophen, mefenamic acid, intramuscular ketorolac tromethamine, and peribulbar anaesthesia in panretinal photocoagulation (PRP).

METHODS

A total of 220 patients with proliferative diabetic retinopathy requiring PRP treatment were enrolled in this study. Before laser treatment, the patients were allocated randomly to one of eight groups: group 1: diazepam (n=22), group 2: acetaminophen (n=21), group 3: mefenamic acid (n=21), group 4: diazepam and acetaminophen (n=22), group 5: diazepam and mefenamic acid (n=22), group 6: peribulbar anaesthesia with lidocaine (n=23), group 7: intramuscular injection of ketorolac tromethamine (n=22), group 8: placebo (n=67). Pain after the laser treatment was assessed by a verbal descriptive scale. Blood pressure and heart rate were measured before and after laser treatment.

RESULTS

Patients receiving peribulbar anaesthesia had a significantly lower pain score than the control group (P<0.0001). Additionally, the peribulbar anaesthesia-treated group had the significantly least PRP-associated rise in either systolic (P=0.043) or diastolic blood pressure rates (P=0.030). There were no significant differences in pain score using other anesthetic agents when compared with the control group. There were no significant changes in heart rate after PRP treatment.

CONCLUSION

Peribulbar anaesthesia is effective in reducing pain and blood pressure increase after PRP treatment. Oral diazepam, mefenamic acid, and acetaminophen (either alone or in combination with each other) are not effective in preventing PRP treatment-associated pain. Intramuscular injection of ketorolac tromethamine is also not effective in reducing PRP-associated pain.

The role of ketorolac in decreasing length of stay and narcotic complications in the postoperative pediatric orthopaedic patient

The control of postoperative pain in the pediatric orthopaedic patient is a challenging endeavor. Several studies have shown the efficacy of ketorolac tromethamine in the pediatric general surgical population, but its efficacy in the pediatric orthopaedic population remains unproven. Twenty-seven consecutive patients (age 6 months to 18 years) who underwent long-bone osteotomies or foot procedures by a group of three pediatric orthopaedic surgeons were given a ketorolac protocol (1 mg/kg loading, 0.5 mg/kg every 6 h for 24 h). Breakthrough pain was managed with morphine until the patient was able to take oral pain medication, as was any pain after the 24-h period for ketorolac expired. Thirty-seven age- and case-matched patients were used as retrospective controls. The patients in the study who received ketorolac required significantly fewer doses of morphine than did the control group (2.29 +/- 3.98 vs. 10.02 +/- 3.39; p < 0.05). In addition the patients on the ketorolac protocol experienced fewer gastrointestinal side effects (4% vs. 32%; p < 0.05). Finally, the patients in the ketorolac group had a significantly shorter length of stay (3.63 +/- 1.64 days vs. 4.74 +/- 1.76 days; p < 0.05). There were no bleeding complications in either group. Ketorolac is thus a safe and effective means of controlling postoperative pain in the pediatric orthopaedic population while avoiding the troubling maleffects seen with the exclusive use of morphine.

Comparison of ketorolac tromethamine, diclofenac sodium, and moist drops for ocular pain after radial keratotomy

PURPOSE

To compare the 2 most popular commercially available topical nonsteroidal anti-inflammatory drugs (NSAIDs) in the treatment of ocular pain following radial keratotomy (RK).

SETTING

Multicenter clinical trial.

METHODS

Ninety-seven RK patients were randomly assigned to 1 of 3 treatment groups: ketorolac tromethamine, diclofenac sodium, and moist drops as a control. The patients used 1 drop of the masked medication and 1 drop of ofloxacin 3 times a day for 3 days prior to surgery. They received 1 drop of the masked medication 1 hour before surgery, immediately after surgery, and 4 times a day thereafter. Patients were given a written questionnaire preoperatively and were also instructed to call a central computerized telephone system to answer prerecorded questions about ocular comfort. The calls were placed 30 minutes and 1, 2, 3, 4, 5, 6, 24, and 48 hours after surgery.

RESULTS

Two hundred ten statistical values were calculated to compare symptoms in the unoperated eye at baseline with symptoms in the operated eyes at each of 9 postoperative time points. Only 7 of the 210 values (3.3%) were significantly different among patient groups (operated versus unoperated eyes) by psychometric testing.

CONCLUSIONS

Both ketorolac tromethamine and diclofenac sodium were more effective in reducing post-RK discomfort than the control (moist artificial tears). Given the large number of tests and the small number that tested as significant, the significant differences (7 of 210 measurements) observed among the 3 treatment groups probably occurred by chance, although the improved foreign-body sensation, functionality, and compliance scores in the ketorolac group during the first 4 hours might be clinically important.

Comparison of the efficacy and safety of ketorolac tromethamine 0.5% and prednisolone acetate 1% after cataract surgery

PURPOSE

To compare the anti-inflammatory and analgesic efficacy and safety of ketorolac tromethamine 0.5% ophthalmic solution with those of prednisolone acetate 1% in patients having cataract surgery.

SETTING

Shawnee Mission Eye Care, Shawnee Mission, Kansas, USA.

METHODS

This double-blind, randomized, single-site study comprised 59 healthy men and women with a clinical diagnosis of routine ocular cataract requiring surgical removal. All patients had extracapsular cataract extraction and posterior chamber intraocular lens implantation. After surgery, patients were randomized to receive ketorolac tromethamine 0.5% or prednisolone acetate 1%, self-instilled in the treated eye, according to the following schedule: 1 to 2 drops 4 times daily (week 1); 3 times daily (week 2); 2 times daily (week 3); once daily (week 4). Patients were examined postoperatively on days 1, 7, and 28. Intraocular anti-inflammatory efficacy was assessed by lid edema, lid injection, conjunctival injection, corneal edema, ciliary flush, and anterior chamber cells. Analgesic efficacy was assessed by patient self-rated pain severity, pain frequency, total symptom sum, and overall global improvement.

RESULTS

Both treatments produced comparable reductions in intraocular inflammation and pain after cataract surgery and were well tolerated by patients. No adverse events were reported, and there were no significant changes in intraocular pressure in either group. Improvements in visual acuity were also similar in both groups.

CONCLUSION

Ketorolac tromethamine 0.5% ophthalmic solution was as effective and well-tolerated as prednisolone acetate 1% solution in controlling postoperative inflammation and pain after cataract surgery.

A comparison of ketorolac tromethamine and acetaminophen codeine in the management of acute apical periodontitis

Effective management of severe endodontic pain is often a major problem. The analgesic effect of ketorolac tromethamine (Toradol, 10 mg p.o.) was compared with acetaminophen codeine (325 mg/15 mg p.o.) in patients with severe pain due to acute apical periodontitis in a double-blind clinical study. A total of 66 patients presenting with severe pain (defined as 7 cm and more using a visual analog scale) were randomly assigned to receive either ketorolac tromethamine or acetaminophen codeine (33 patients in each group), and recorded their pain score once every 10 min for 90 min after administration. Results indicate that patients in the ketorolac group had significantly less pain than those who received acetaminophen codeine (p = 0.005).

Lumbar versus thoracic epidural buprenorphine for postoperative analgesia following coronary artery bypass graft surgery

BACKGROUND

Thoracic epidural analgesia (TEA) is reported to provide effective analgesia following cardiac surgery. We compared the effect of buprenorphine (BN) through the lumbar and thoracic epidural routes for postoperative analgesia following coronary artery bypass graft surgery (CABG).

METHODS

Forty patients with normal left ventricular ejection fraction scheduled for CABG were randomly divided into two groups, the TEA group (n = 19) and the lumbar epidural analgesia (LEA) group (n = 20). For postoperative pain relief they received epidural BN 0.15 mg at the first demand for pain relief following extubation. A top-up dose of BN 0.15 mg was administered in cases where visual analogue scale (VAS) score was > 3 at 1 h after first dose. Subsequent breakthrough pain was treated with 30 mg intramuscular ketorolac tromethamine (ketorolac). Pain assessed by VAS score on a 0-10 scale, respiratory rate, FEV1, FVC, mean arterial blood pressure, cardiac index, PaO2 and PaCO2 were measured at frequent intervals. Side effects of epidural opioids were noted.

RESULTS

Both groups were comparable in demographic characteristics, had similar VAS scores from 1 to 24 h postoperatively, required similar amounts of intramuscular ketorolac for break-through pain and had comparable pulmonary functions and side effects.

CONCLUSION

This study shows that BN by the lumbar epidural route for analgesia after CABG compares favourably with the same drug through the thoracic route in terms of quality of analgesia and incidence of side effects.

Efficacy and safety profile of ketorolac 0.5% ophthalmic solution in the prevention of surgically induced miosis during cataract surgery

This multicenter, double-masked, randomized, parallel study compared the efficacy and safety profile of ketorolac tromethamine 0.5% ophthalmic solution with that of its vehicle in the maintenance of pupillary mydriasis during cataract surgery. A total of 176 adult patients scheduled to undergo unilateral extracapsular cataract extraction and posterior-chamber intraocular lens implantation received either ketorolac tromethamine 0.5% (n = 89) or vehicle (n = 87), starting 2 hours before surgery. One drop of study medication was instilled every 30 minutes for a total of 4 drops. No epinephrine was used in the intraoperative irrigating solution. Pupil diameter was measured with a caliper at 3 time points during surgery. To ensure participant safety, biomicroscopy, ophthalmoscopy, intraocular pressure, adverse events, and preoperative and postoperative visual acuity and refractive error were also monitored. The mean change in horizontal and vertical pupil diameter from the time of the first incision to after cortical irrigation and aspiration was significantly less with active ketorolac than with vehicle (P < or = 0.014). Consequently, mean pupil diameter after cortical irrigation and aspiration was significantly greater with ketorolac than with vehicle (P < or = 0.030). No significant between-group differences were observed in the change in pupil diameter between the end of surgery and postoperative administration of a miotic agent, safety variables, or occurrence of adverse events. In this study, ketorolac tromethamine 0.5% ophthalmic solution provided effective and well-tolerated inhibition of surgically induced miosis during cataract surgery.

Comparative effects of intravenous ketorolac and pethidine on perioperative analgesia and postoperative nausea and vomiting (PONV) for paediatric strabismus surgery

BACKGROUND

Corrective strabismus surgery is associated with moderate pain and a very high incidence of postoperative nausea and vomiting (PONV). Ketorolac tromethamine, a nonsteroidal anti-inflammatory drug, is a popular analgesic in adults. There are only limited published data on the use of intravenous ketorolac for paediatric analgesia perioperatively. This study evaluated and compared the emetic and analgesic effect of ketorolac with pethidine and its suitability for this kind of surgery.

METHODS

Following institutional ethics committee approval and parental consent, 52 ASA class I children of age 2.5 to 15 yr were randomised to receive either ketorolac 0.9 mg kg-1 or pethidine 0.5 mg kg-1 given intravenously (i.v.). A blinded observer assessed recovery by Steward's method immediately after arrival at the post anaesthesia care unit (PACU), pain by validated Objective Pain Score (OPS) at 0 h, 1/2 h and 1 h after arrival at the PACU and PONV by Numeric Rank Score at specified time intervals.

RESULTS

There were no differences in demographic data, anaesthesia time or surgery duration. Recovery scores, OPS and postoperative analgesic requirement were similar in both groups. PONV at various time intervals for the first 24 h, occurred more frequently in the pethidine group as compared to the ketorolac group (P < 0.001) There were no side effects observed with either drug.

CONCLUSION

Ketorolac in a dose of 0.9 mg kg-1 i.v. at the induction of anaesthesia is as effective as pethidine 0.5 mg kg-1 i.v. as an analgesic and is associated with significantly less PONV.

[Ways of improving postoperative analgesia]

Analysis of many-year experience gained in the use of a variety of methods and means for treating the painful syndrome in victims and patients after planned and urgent surgery allowed the authors to determine the optimal approaches to postoperative analgesia. Special attention is paid to introduction of new drugs and methods of analgesia with differentiated approach to prevention and treatment of the painful syndrome. A conclusion on the necessity of pathogenetically based and strictly individual postoperative analgesia is made; such analgesia is often to be multilevel and multicomponent, with consideration for the complex origin of painful reaction (including the components of the painful syndrome) and the armory of available means.

Ketorolac tromethamine 0.5% ophthalmic solution in the treatment of moderate to severe ocular inflammation after cataract surgery: a randomized, vehicle-controlled clinical trial

PURPOSE

To investigate the efficacy and safety of ketorolac tromethamine 0.5% ophthalmic solution (Acular; Allergan, Inc, Irvine, California) in the treatment of moderate to severe anterior segment inflammation developing after unilateral cataract surgery with intraocular lens implantation.

METHODS

Only patients who exhibited moderate or greater levels of cells and flare 1 day after surgery were included in this multicenter, double-masked, randomly assigned, parallel-group study. Topical ketorolac or vehicle solution (Allergan, Inc) was administered to the treated eye four times daily, starting the day after surgery and continuing for 14 days.

RESULTS

Ketorolac was significantly more effective than the vehicle solution in reducing anterior chamber cells (P < or = .030) and flare (P < or = .025), conjunctival erythema (P < or = .046), ciliary flush (P < or = .006), tearing (P < or = .012), photophobia (P < or = .014), and pain (P < or = .049). Half as many patients from the ketorolac group (14/51) were discontinued from the study for lack of efficacy, compared with the vehicle group (28/51; P = .005). There was no significant difference between ketorolac and the vehicle solution in changes in visual acuity, intraocular pressure, biomicroscopic or ophthalmoscopic variables, or adverse events.

CONCLUSIONS

Ketorolac tromethamine 0.5% ophthalmic solution is safe and provides substantial anti-inflammatory activity in the treatment of moderate to severe anterior segment inflammation developing after cataract surgery and intraocular lens implantation.

[Postoperative oxadol analgesia in oncologic patients]

Oxadol (nefopam hydrochloride), a central analgesic, was used for postoperative pain relief in patients operated on the abdominal and pelvic organs for cancer. The analgesic effect of oxadol was sufficient for arresting moderate postoperative pain. Although the drug exerts rather many side effects, none of them notably deteriorated the clinical status of patients.

A double-blind evaluation of the analgesic efficacy and toxicity of oral ketorolac and diclofenac in cancer pain. The TD/10 recordati Protocol Study Group

AIM

To compare the analgesic efficacy and toxicity of the nonsteroidal anti-inflammatory analgesic drug, ketorolac (Toradol, Recordati spa, Milan) 10 mg p.o. (t.i.d.) with diclofenac (Voltaren, Novartis Farma, Origglo, VA) 50 mg p.o. (t.i.d.) in cancer patients with moderate to severe chronic pain.

METHODS AND STUDY DESIGN

The study was a multicenter randomized double-blind cross-over trial. Each treatment lasted 7 days, after which the patients crossed over to the other drug. Pain intensity was evaluated by the visual analogue scale (VAS) after the first dose and by the 5-point verbal rating scale (VRS) by the patient and by the physician following the 7-day treatment.

RESULTS AND CONCLUSIONS

A total of 138 advanced cancer patients were enrolled in the study. Overall 251 single-dose administrations (117 cross-over observations) and 257 multiple treatments (127 cross-over experiments) were assessable. After a single administration of ketorolac and diclofenac, no significant difference could be observed in analgesic activity, as indicated by the area under the pain-intensity time curve (AUC0-8), in the maximum efficacy, or the duration of efficacy of the two drugs. The Westlake confidence intervals of the AUC0-8 ratio (ketorolac: diclofenac) (1.07; 90% CI, 0.94-1.19), of the maximum efficacy ratio (1.03; 90% CI, 0.92-1.14), and the duration of efficacy ratio (1.05; 90% CI, 0.97-1.11) showed the bioequivalence of the two drugs. Satisfactory pain relief was reported for multiple 7-day treatments, with no significant differences between the two therapies: according to the physician's evaluation, in 93/128 (73%; 95% CI, 65-80%) ketorolac treatments and 91/129 (71%; 95% CI, 63-78%) diclofenac treatments; according to the patient's evaluation, in 83/128 cases (65%; 95% CI, 57-73%) after ketorolac and in 74/129 cases (57%; 95% CI, 49-66%) after diclofenac. Adverse symptoms were acceptable with both drugs. Interestingly, a pronounced sequence effect was found: gastric disturbances after ketorolac were observed mainly (10 out of 15 observed events) when the drug was given to patients pretreated with diclofenac.

Postoperative hemorrhage after tonsillectomy: use of ketorolac tromethamine

Recent reports have associated an increased incidence of bleeding after tonsillectomy with the perioperative use of ketorolac tromethamine. To review this association, we examined the hospital and office records of 310 pediatric patients who underwent tonsillectomy with or without adenoidectomy at our institution during a 2-year period. Of these patients, 213 received ketorolac administered as a single dose at the conclusion of the procedure. The remaining 97 patients did not receive ketorolac. The frequency of postoperative hemorrhage was not found to differ significantly between these 2 groups (2.3% vs. 3.1% respectively, P = 0.71). Furthermore, the average time to discharge after surgery was significantly shorter in those patients who received ketorolac than in those who did not (8.5 hours vs. 12.5 hours, respectively, P < 0.0001). The frequency of overnight hospital stays was also significantly lower in those patients who received ketorolac (16.0% vs. 31.6%, respectively, P < 0.01). Concern over the potential for increased hemorrhage after tonsillectomy has led several authors to caution against the use of ketorolac in this setting. In our study, however, the use of ketorolac was not found to increase the incidence of posttonsillectomy hemorrhage and furthermore was associated with a significant decrease in the length of hospital stay as well as a decreased likelihood of overnight hospital stay after surgery.

Efficacy and safety of nonpreserved ketorolac ophthalmic solution in postoperative ocular pain following radial keratotomy

PURPOSE

To investigate the efficacy and safety of nonpreserved ketorolac tromethamine 0.5% ophthalmic solution in relieving pain following radial keratotomy (RK).

SETTING

Multicenter clinical trial.

METHODS

Topical ketorolac was compared with its vehicle in a double-masked, randomized, parallel-group study involving 170 RK patients. Patients were treated with nonpreserved ketorolac 0.5% ophthalmic solution or the vehicle 4 times daily beginning immediately after surgery and continuing for 3 days or until they no longer had ocular pain.

RESULTS

At several intervals, patients treated with ketorolac reported significantly greater pain relief and less pain intensity than patients treated with the vehicle. The time required for patients to first report "complete relief" or "no pain" was shorter in the ketorolac than in the vehicle group (P < or = .006). Patients in the ketorolac group used less escape medication (acetaminophen) (P < or = .001) and had fewer sleep difficulties (P < or = .031), fewer symptoms of ocular discomfort (P < or = .028), and less difficulty performing activities of daily living (P = .048). Patients treated with ketorolac experienced the same low rate of treatment-related adverse events as those treated with the vehicle and exhibited the same improvement in visual acuity and manifest refraction.

CONCLUSIONS

Nonpreserved ketorolac tromethamine 0.5% ophthalmic solution was significantly more effective than, and as safe as, the vehicle in alleviating the postoperative pain associated with RK. This resulted in significant improvements in patient quality of life and less need for oral analgesics, suggesting that topical ketorolac is an appropriate treatment option for ocular pain following RK.

Immunomodulation with interleukin-10 and interleukin-4 compared with ketorolac tromethamine for prevention of postoperative adhesions in a murine model

OBJECTIVE

To assess the effects of two macrophage down-regulating cytokines (interleukin [IL]-10 and IL-4) and the nonsteroidal anti-inflammatory drug ketorolac tromethamine on postoperative adhesion formation.

DESIGN

Randomized controlled trial.

SETTING

Research center vivarium.

ANIMAL(S)

Six-week-old Swiss Webster mice.

INTERVENTION(S)

One hundred eighty animals were randomized to serve as nonsurgical controls or to undergo a standardized adhesion-inducing procedure. Subsequently, animals were randomized to nine different treatment groups to receive no injections, phosphate-buffered saline (PBS) only, IL-10, IL-4, ketorolac, IL-10 plus IL-4, IL-10 plus ketorolac, IL-4 plus ketorolac, or all three agents.

MAIN OUTCOME MEASURE

Adhesion scores on postoperative day 10.

RESULT(S)

Postoperative adhesion scores were significantly reduced in all groups of animals treated with IL-10 or ketorolac. Animals treated with IL-4 showed a nonsignificant trend toward reduction of adhesions. There were significantly more animals with adhesion scores of < or = 3 in the IL-10 and ketorolac treatment groups than in the control groups receiving no treatment or PBS only.

CONCLUSION(S)

Although treatment with IL-10 and ketorolac did not completely prevent adhesion formation, treatment with these drugs did lead to a significant reduction in adhesion formation. Adhesions also tended to be thin and filmy rather than thick and vascular. Addition of IL-4 did not augment these effects.

Efficacy of ketorolac tromethamine versus meperidine in the ED treatment of acute renal colic

To compare the efficacy of intramuscular ketorolac and meperidine in the emergency department (ED) treatment of renal colic, a prospective, controlled, randomized, double-blind trial was conducted in an academic ED with 76,000 annual visits. Participants were volunteer ED patients with a diagnosis of ureterolithiasis confirmed by intravenous pyelogram. Subjects were randomized 1:1 to receive a single intramuscular injection of either 60 mg ketorolac or 100 to 150 mg meperidine, based on weight. Of the 70 patients completing the trial, 33 received ketorolac and 37 received meperidine. Demographic characteristics and baseline pain scores of both groups were comparable (P = NS, Mann Whitney U). Ketorolac was significantly (P < .05) more effective than meperidine in reducing renal colic at 40, 60, and 90 minutes as measured on a 10-cm visual analogue scale. Similar proportions of patients in each group were given rescue analgesia and admitted. Of patients who were discharged home without rescue, those treated with ketorolac left the ED significantly earlier than those treated with meperidine (3.46 v 4.33 h, P < .05). These results show that intramuscular ketorolac as a single agent for renal colic is more effective than meperidine and promotes earlier discharge of renal colic patients from the ED.

Effects of ketoralac tromethamine and indomethacin on primary and secondary bone healing. An experimental study in rats

Ketoralac tromethamine is a new non-steroidal anti-inflammatory drug that is being used extensively as an analgesic in orthopaedic surgery, particularly for outpatient procedures. However, as with all non-steroidal anti-inflammatory drugs there have been theoretical concerns about the effect of the drug with regard to bone metabolism and healing. In the present study bone healing of femoral osteotomies was evaluated in rats given ketoralac tromethamine in comparison with two other groups of rats given indomethacin and saline (control group), respectively. Under unstable healing conditions, 3 days of medication with indomethacin significantly reduced the femoral bending moment, bending rigidity and energy expenditure compared with the control group. Such impairment of mechanical characteristics was not found during the first 3 days after osteotomy in rats given ketoralac tromethamine. There were no significant differences in mechanical properties between the three groups when healing occurred under stable conditions. Ketoralac tromethamine is a rather new NSAID that has excellent aqueous solubility and lacks tissue irritability [2]. It is, therefore, very suitable for parenteral use. Additionally, it is the most potent NSAID known, equal or superior to morphine for pain relief following orthopaedic surgery [9]. Its use has therefore become widespread as an alternative to opioid analgesics [7]. Its effects on bone metabolism and healing have, however, not been fully elucidated, and concern has been expressed about its potential effect. The present study was designed to investigate the effects of short-term administration of ketoralac tromethamine on bone healing under stable and unstable conditions in rats, as compared to indomethacin.

A comparison of ketorolac tromethamine/oxycodone versus patient-controlled analgesia with morphine in anterior cruciate ligament reconstruction patients

Effective postoperative analgesia with minimal side effects remains an important goal in enabling increasingly complex surgical procedures to be performed on an outpatient basis. In this study, we examined the efficacy of postoperative analgesia in 90 patients undergoing anterior cruciate ligament reconstruction using a patellar tendon autograft, with a 24-hour hospital stay. Patients were randomized to receive either intramuscular ketorolac supplemented by oral oxycodone, or intravenous morphine via patient-controlled analgesia (PCA) device, for postoperative analgesia. Patients were monitored for 2 hours in the recovery room, then every 4 hours until discharge, for the presence of complications of nausea, vomiting, urinary retention, pruritus, and dizziness. Pain was assessed using a visual analog scale (VAS) on the morning of postoperative day one. All patients were discharged by 24 hours after surgery. Ten (20%) of the patients receiving ketorolac/oxycodone versus 31 (79%) of those receiving PCA morphine experienced postoperative complications (P < .05). Postoperative nausea, vomiting, and urinary retention were each significantly more common in the PCA morphine group (P < .05). The incidence of pruritus and dizziness was low overall. There was no significant difference between groups in the severity of postoperative pain as assessed using a VAS. We conclude that ketorolac/oxycodone may provide comparable analgesia with fewer undesirable side effects than PCA morphine in patients undergoing anterior cruciate ligament reconstruction. Patients receiving ketorolac/oxymorphone may have a better quality recovery and more rapid discharge.

Effect of intra-articular versus systemic anti-inflammatory drugs in a rabbit model of temporomandibular joint inflammation

PURPOSE

In an attempt to better understand the time course of inflammatory mediator production or release in inflammatory joint disease, a rabbit model of acute temporomandibular joint (TMJ) inflammation was established. This model was used to evaluate the effects of specific anti-inflammatory agents administered either systemically (intraperitoneal, IP) or locally (intra-articular, IA) on the modulation of in vivo tissue levels of two prototypic inflammatory mediators, prostaglandin E2 (PGE2) and bradykinin (BK).

MATERIALS AND METHODS

An experimental model of inflammation was created by administering carrageenan (carra) into one joint and an equivalent volume of saline (control) into the contralateral joint of 42 male New Zealand White rabbits. The development of hyperthermia was assessed by placement of a microthermister probe into the joint space. The inflammatory mediators, immunoreactive PGE2 (iPGE2) and BK (iBK), were recovered with microdialysis probes, and samples were assayed in conjunction with specific pharmacologic interventions. In the first part of the study, the time course for the release or production of iBK and iPGE2 was determined. In the second part, the effects of IP versus IA administration of dexamethasone and a nonsteroidal anti-inflammatory drug, ketorolac tromethamine, were compared. Dexamethasone and ketorolac were administered at 3 hours and 1 hour, respectively, before the peak release of the inflammatory mediators.

RESULTS

The onset of IA hyperthermia, an index of inflammation, was evident by 90 minutes post-carra and reached a maximum of 1.2 degrees C above core temperature by 150 minutes post-carra. Intra-articular levels of iPGE2 and iBK peaked at 240 minutes (3.35+/-1.9 nmol/L) and 270 minutes (0.45+/-0.29 nmol/L), respectively, after the induction of inflammation in the superior joint space. iBK levels within the superior joint space were significantly decreased by dexamethasone and ketorolac. Ketorolac (50 microg) decreased iBK and iPGE2 levels when given IA or IP. With dexamethasone (3 mg), the levels of iBK were significantly reduced, and iPGE2 levels were not changed.

CONCLUSIONS

This study shows that the rabbit model of TMJ inflammation, with concurrent collection of iBK and iPGE2 via microdialysis, is a reproducible and reliable method to investigate the time course of inflammatory mediator release and their modulation by either the local or systemic administration of anti-inflammatory medications.

A comparative study of ketorolac (Toradol) and magnesium sulfate for arrest of preterm labor

BACKGROUND

We evaluated the efficacy and safety of ketorolac (Toradol).

METHODS

In this prospective trial, 88 women in confirmed preterm labor at < or =32 weeks' gestation were randomized to receive magnesium sulfate given as an initial 6 g intravenous bolus followed by continuous infusion therapy (2 to 6 g/hr) or intramuscularly administered ketorolac (60 mg loading dose) followed by 30 mg every 6 hours for a maximum of 24 hours.

RESULTS

The study groups were similar with respect to age, parity, cervical status, and gestational age on admission. Ketorolac was more rapid (2.71 hr+/-2.16) in the arrest of preterm labor than was magnesium sulfate (6.22 hr+/-5.65). No patient required discontinuance of either drug due to adverse effects. There was no difference in the incidence of neonatal complications between the two groups.

CONCLUSION

In gestations with preterm labor at <32 weeks, ketorolac appears to be an appropriate first-line tocolytic agent.

The efficacy of sublingual hyoscyamine sulfate and intravenous ketorolac tromethamine in the relief of ureteral colic

A prospective, randomized, open-label, single-dose study was conducted in an emergency department (ED) of a tertiary care teaching hospital to evaluate the efficacy of hyoscyamine sulfate as compared to ketorolac tromethamine for the reduction of pain from ureteral colic in the ED. Patients were included if they were at least 18 years of age and presented to the ED with an initial history and physical examination consistent with ureteral colic. Ureteral calculi were confirmed by ultrasound or intravenous urogram. Consecutive patients were randomized to either a single sublingual dose of 0.125 mg of hyoscyamine sulfate or a single intravenous dose of 30 mg of ketorolac tromethamine given over 1 minute. After 30 minutes, if analgesia was inadequate, patients were given rescue medication. Baseline pain scores were obtained using a horizontal, 100-mm visual analog scale. Additional pain scores were obtained at 10-minute intervals for 30 minutes. Upon completion of the study, both patients and physicians completed a global assessment score questionnaire. Fifty-four evaluable patients were randomized. Demographics and baseline pain scores were similar for each group. Decreasing trends in pain over time were observed for both treatment groups, with significantly greater pain reduction observed with ketorolac tromethamine as compared to hyoscyamine sulfate. Global evaluations of pain relief revealed better results in the ketorolac tromethamine group than in the hyoscyamine sulfate group, although this result was not statistically significant.

Comparison of oral ketorolac and hydrocodone for pain relief after anterior cruciate ligament reconstruction

The analgesic effectiveness of ketorolac tromethamine was compared with hydrocodone and acetaminophen for pain from an arthroscopically assisted patellar-tendon autograft anterior cruciate ligament reconstruction. There were 125 patients evaluated in a double-blind, randomized, multicenter, and multidose study. A loading dose of parental ketorolac tromethamine was administered and subjects were later given two staged doses of the same "unknown" drug with pain evaluations conducted after each dose. For group 1, dose 1 consisted of ketorolac tromethamine 20 mg orally and dose 2 was ketorolac tromethamine 10 mg. For group 2, both dose 1 and dose 2 consisted of hydrocodone 10 mg plus acetaminophen 1,000 mg orally. Efficacy was evaluated by standard analgesic measures. Subjects treated as outpatients showed lower categorical pain intensity for ketorolac tromethamine than hydrocodone and acetaminophen at 1 hour (P=.03), 2 hours (P=.006), and 3 hours (P=.02); lower summed intensity differences for ketorolac tromethamine than hydrocodone and acetaminophen at 3 hours (P=.014) and 4 hours (P=.019); and better total pain relief for ketorolac tromethamine than hydrocodone and acetaminophen at 3 hours (P=.014) and 4 hours (P=.013). With an effective loading dose administered before the subsequent oral dosage, there was statistically better pain reduction with ketorolac tromethamine than with hydrocodone and acetaminophen. Moreover, ketorolac tromethamine was no more likely to cause digestive complaints than hydrocodone and acetaminophen. No bleeding problems were observed in either group. In the outpatient setting, ketorolac tromethamine controls postoperative pain better than hydrocodone and acetaminophen in the immediate postsurgery period.

Minimizing hospital length of stay in children undergoing ureteroneocystostomy

OBJECTIVES

Shortening hospital stay yet not compromising quality of care can result in significant cost savings for children undergoing surgical correction of vesicoureteral reflux.

METHODS

We reviewed the medical records of pediatric patients who underwent ureteroneocystostomy between July 1995 and July 1997. A total of 43 patients, aged 0.2 to 18 years (mean 5.2) who all received identical postoperative care, except for their pain management and the time of bladder catheter removal, were included in the study. Twenty-three were treated with intravenous ketorolac tromethamine (Toradol); the remaining 20 received narcotics in the immediate postoperative period. The bladder catheter was removed in less than 24 hours in 22 children, and greater than 24 hours in 21.

RESULTS

Patients who received ketorolac tromethamine for postoperative analgesia had on average shorter hospital length of stays than those treated with narcotics (1.4 versus 2.5 days, respectively; P < 0.001). The average stay for children whose bladder catheter was removed within 24 hours postoperatively was significantly shorter than those whose catheter was removed after a 24-hour period (1.4 versus 2.4 days, respectively; P < 0.001). There were no reimplantation failures. One child presented 2 days postoperatively with anemia, which did not require transfusion.

CONCLUSIONS

Our review demonstrates that ketorolac tromethamine can be used safely and effectively in children for immediate postoperative analgesia, and that its proper use combined with early catheter removal can reduce the length of hospital stay for pediatric patients undergoing ureteroneocystostomy.

Comparative effects of ketorolac 0.5% or diclofenac 0.1% ophthalmic solutions on inflammation after cataract surgery

OBJECTIVE

Ketorolac tromethamine 0.5% and diclofenac sodium 0.1% ophthalmic solutions are approved for use by the U.S. Food and Drug Administration to avoid excessive postoperative inflammation after cataract surgery and implantation of an intraocular lens. This study compares the efficacy and toxicity of these nonsteroidal anti-inflammatory drugs for the first time.

DESIGN

Randomized, double-masked, prospective clinical trial.

PARTICIPANTS

A total of 120 patients assigned in equal numbers to 1 of the 2 treatment regimens.

INTERVENTION

Treatment with either ketorolac 0.5% or diclofenac 0.1% ophthalmic solutions instilled four times daily for 30 days beginning the first postoperative day after surgery.

MAIN OUTCOME MEASURES

Objective (Kowa FC 1000 laser cell and flare meter) and subjective (slit-lamp biomicroscope) measurements of inflammation and toxicity were made and compared at three separate post-operative visits.

RESULTS

The anti-inflammatory effects of the two treatment regimens were not statistically different at any of the postoperative visits. Patients tolerated both treatments equally well.

CONCLUSIONS

This study shows diclofenac sodium 0.1% and ketorolac tromethamine 0.5% ophthalmic solutions are equally effective and safe for the control of postoperative inflammation after uncomplicated cataract surgery performed by phacoemulsification followed by the implantation of a foldable intraocular lens.

A randomized double-masked trial comparing ketorolac tromethamine 0.5%, diclofenac sodium 0.1%, and prednisolone acetate 1% in reducing post-phacoemulsification flare and cells

BACKGROUND AND OBJECTIVE

To compare the efficacy of ketorolac tromethamine 0.5%, diclofenac sodium 0.1%, and prednisolone acetate 1% in reducing flare and cells following cataract surgery.

PATIENTS AND METHODS

Fifty-eight patients undergoing phacoemulsification with posterior chamber intraocular lens implantation were randomly selected to receive either ketorolac tromethamine 0.5%, diclofenac sodium 0.1%, or prednisolone acetate 1% following surgery. The treatment regimen was 1 drop 4 times a day for 1 week, then twice a day for the next 3 weeks. Flare, cells, and intraocular pressures (IOPs) were measured preoperatively and on postoperative days 1, 7, and 28.

RESULTS

No statistically significant differences in either actual flare or cell counts or in change in flare or cell counts from baseline were detected among the three groups. No statistically significant differences in IOP or in change of IOP from preoperative measurements were detected. No medication-related complications were noted at any time.

CONCLUSION

Ketorolac tromethamine 0.5% and diclofenac sodium 0.1% may be as effective and as safe as prednisolone acetate 1% in controlling inflammation following cataract extraction.

Effects of ketorolac tromethamine mouthrinse (0.1%) on crevicular fluid prostaglandin E2 concentrations in untreated chronic periodontitis

The effects of topical ketorolac tromethamine mouthrinse (0.1%) on gingival crevicular fluid (GCF) prostaglandin E2 (PGE2) concentrations were investigated in a 6-week, randomized, double-blind, placebo-controlled, parallel group, single center study of 42 patients with moderately advanced chronic adult periodontitis. Following screening, GCF was sampled from 6 sites per subject with filter paper strips and PGE2 levels measured using an enzyme immunoassay kit. Only those subjects with mouth median GCF PGE2 concentrations >30 ng/ml entered the rinsing phase. Eligible subjects were allocated placebo rinse in the first 2-week period (days 0 through 14), either ketorolac rinse (test group, n = 21) or placebo rinse (control group, n = 21) in the second 2-week period (days 14 through 28), and placebo rinse in the third 2-week period (days 28 through 42). Full mouth median GCF PGE2 concentrations were calculated for each subject at days 0, 14, 28, and 42, and group means were compared. From day 0 to day 14, no significant changes in GCF PGE2 concentrations were detected in either study group (P > 0.05). Utilizing mean GCF PGE2 concentrations at days 0 and 14 as covariates, no significant differences were observed in adjusted mean PGE2 levels at days 28 and 42 between the study groups (ANCOVA, P > 0.05). A statistically significant increase in GCF PGE2 levels was noted at days 28 and 42 in the placebo group (P < 0.01), but not in the ketorolac group (P > 0.05), when compared to baseline, however. GCF PGE2 levels were further studied in a subset of volunteers (n = 11) during a 12-hour period following first rinsing with mouthrinse (active or placebo) at day 14. GCF was sampled 0, 2, 4, 6, 8, and 12 hours post-rinsing. Mean PGE2 levels were higher in the placebo subgroup than in the ketorolac subgroup, and increased gradually over the 12-hour period in both subgroups. These data indicate that 1) 14 days of rinsing with 0.1% ketorolac mouthrinse controlled the elevation of GCF PGE2 observed in the placebo group but did not actually reduce GCF PGE2 concentrations and 2) changes in GCF PGE2 levels were not detectable in the 12-hour period following first rinsing with ketorolac.

Ketorolac (Toradol) as an analgesic in swine following transluminal coronary angioplasty

Post-procedure pain is a common complication in swine following survival angioplastic procedures. Ketorolac and buprenorphine have been used to control pain in these animals. Time from completion of procedure-extubation to onset of feeding was used as an indicator for analgesic effect. The onset of feeding following extubation occurs within 6 to 20 h in animals given ketorolac compared to 30 plus hours in animals given buprenorphine.

The effects of topical nonsteroidal anti-inflammatory drugs on adenoviral replication

OBJECTIVE

To evaluate the antiviral activity of topical diclofenac sodium (Voltaren Ophthalmic) and ketorolac tromethamine (Acular) (2 nonsteroidal anti-inflammatory drugs [NSAIDs]) on adenoviral replication in vitro and in the adenovirus (Ad) 5 McEwen-New Zealand rabbit ocular model.

METHODS

The 50% inhibitory concentration of ketorolac and diclofenac and their respective preservative components were determined for common ocular adenoviral serotypes (Ad8, Ad19, Ad1, and Ad5). In a series of experiments, Ad5 McEwen-inoculated New Zealand rabbit eyes were treated topically 4 times daily for 18 days with either ketorolac, diclofenac, prednisolone acetate (Pred Forte), or control vehicle (Comfort Tears).

MAIN OUTCOME MEASURES

Outcome measures included serial ocular tear film titers and the formation of subepithelial immune corneal infiltrates.

RESULTS

In vitro, neither ketorolac nor diclofenac demonstrated significant inhibitory activity against Ad1, Ad5, Ad8, or Ad19. In the rabbit model, there were no statistically significant differences among ketorolac, diclofenac, and the control vehicle with respect to viral replication or the formation of subepithelial immune infiltrates. In contrast, 1% prednisolone prolonged viral shedding and inhibited immune infiltrates (P < .001 for both).

CONCLUSIONS

Our experimental study suggests that treatment of epidemic keratoconjunctivitis with topical NSAIDs may be a safer alternative than topical steroids. Only controlled clinical trials can determine whether topical NSAIDs can provide symptomatic relief and not interfere with normal viral clearance.

Plasma prostaglandin E2 concentrations after single dose administration of ketorolac tromethamine (Toradol) in dogs

Ketorolac tromethamine (Toradol) is a relatively new, potent, non-narcotic analgesic with cyclooxygenase (COX) inhibitory activity and has been associated with gastric and renal toxicity in people and dogs. The objectives of this study were to establish whether endogenous PGE2 exists in the plasma of healthy dogs and to determine if, and to what magnitude, ketorolac alters PGE2 plasma concentrations after administration. Enzyme immunoassay measurement of a stable PGE2 derivative, bicyclo PGE2, showed that after i.v. administration of 0.5 mg/kg ketorolac tromethamine, 1 and 24 h plasma samples contained significantly (P < or = 0.01) less PGE2 than did plasma samples collected from dogs before the drug treatment. After p.o. administration, 1 h plasma samples contained significantly (P < or = 0.01) less PGE2 than did pretreatment samples, and the 24 h post-drug administration samples contained significantly (P < or = 0.01) less plasma PGE2 than the 96 h plasma samples. The results of this study suggest that a clinically effective single i.v. or p.o. dose of ketorolac tromethamine to healthy dogs causes a significant but reversible decrease in endogenous PGE2 production which may partially explain the drug's low therapeutic index.

Intra-articular injection of ketorolac in the rat knee joint: effect on articular cartilage and synovium

We have investigated the effects of intra-articular (i.a.) administration of ketorolac in the rat knee joint. Thirty Sprague-Dawley rats were given 0.25 ml of a standard preparation of ketorolac trometamol (10 mg ml-1) by injection into the right knee joint and 0.25 ml of 0.9% physiological saline solution by injection into the left knee as a control. Ten rats were killed at 24 h, 10 at 48 h and 10 at 5 days after injection. The joints were prepared and sectioned for histological examination. There was significantly more inflammation in those knees that had received i.a. ketorolac at all times of examination, with the most severe changes occurring 5 days after injection. A further group of 10 rats were given 0.25 ml of 10% w/v ethanol in physiological saline (similar to the vehicle for parenteral ketorolac) injected into the knee joint, with a 0.9% saline control injected in the other knee. These rats were then killed at 5 days (as this was the time interval after which we found the maximum inflammatory response in the earlier phase of our study). The joints were prepared and examined histologically. We feel that the absence of inflammatory changes in these joints make it unlikely that ethanol was responsible for the inflammation produced by ketorolac injection.

Preemptive pain control in patients having laparoscopic hernia repair: a comparison of ketorolac and ibuprofen

OBJECTIVES

To determine if nonsteroidal anti-inflammatory drugs provide adequate pain control for patients having laparoscopic hernia repair and to compare the effectiveness of ketorolac tromethamine with ibuprofen in reducing postoperative laparoscopic hernia pain.

DESIGN AND SETTING

Prospective double-blind randomized study at a 100-bed community hospital.

PATIENTS

Seventy patients ranging in age from 16 to 83 years scheduled for elective laparoscopic inguinal hernia repair.

INTERVENTIONS

Patients undergoing laparoscopic hernia repair were enrolled in a double-blind randomized study to compare the 2 treatments. Group 1 received a placebo capsule 1 hour before surgery and ketorolac tromethamine, 60 mg intravenously, at the time of trocar insertion. Group 2 received ibuprofen, 800 mg an hour before surgery, and isotonic sodium chloride solution, 2 mL intravenously, at the time of trocar insertion. In addition, all patients received local infiltration of 30 mL of bupivacaine hydrochloride into their trocar sites. All patients were discharged within 5 hours of the operation and were instructed to take 400 mg of ibuprofen orally every 4 hours for 24 hours whether or not they were experiencing pain. A 24-hour supply of ibuprofen was provided to all study patients. Pain was assessed using the Visual Analog Pain Scale with a maximum pain rating of 100. Assessments were done at the time of and 18 hours after discharge.

MAIN OUTCOME MEASURE

Postoperative pain 18 and 24 hours after discharge was assessed using a standardized questionnaire in a telephone interview by a registered nurse from the Outpatient Surgical Unit.

RESULTS

There was no significant difference in the level of pain experienced by 35 patients who received ketorolac intravenously and 35 who received ibuprofen orally. There was no significant difference between the 2 treatment groups in the amount of pain experienced at discharge and 18 hours after discharge.

CONCLUSIONS

Pain relief from ibuprofen, 800 mg, administered orally an hour before laparoscopic hernia repair was not statistically different from that obtained with intravenous ketorolac, 60 mg, administered intraoperatively when comparing the hospital discharge pain score and the mean and highest pain scores 18 hours after discharge. Ibuprofen offers equivalent pain control at a lower cost and reduced potential for adverse drug events compared with intravenous ketorolac in patients having laparoscopic hernia repair. No patient required narcotic supplementation, and pain control was judged satisfactory by all the patients.

Effect of ketorolac tromethamine (Toradol) on ischemia-reperfusion injury in skeletal muscle

The eicosanoids, leukotriene B4 (LTB4) and thromboxane A2 (TXA2), contribute to neutrophil adhesion and arteriole vasoconstriction, important microcirculatory events in ischemia-reperfusion (I-R) injury. The purpose of this study was to evaluate the effect of ketorolac on I-R injury of skeletal muscle. A videomicroscopic preparation of gracilis muscle in male Wistar rats (n=7) in two experimental groups was evaluated: Group 1-4 hr global ischemia only (19 arterioles, 19 venules), and Group 2-4 hr ischemia plus ketorolac (13 arterioles, 14 venules). Ketorolac (0.86 mg/kg, i.m.) was given 30 min prior to reperfusion. The number of neutrophils, rolling and adherent, was counted in 100-micron venular segments, and arteriole diameters were measured at 5, 15, 30, 60 and 120 min of reperfusion. The I-R-induced increase in neutrophil adhesion was significantly reduced by ketorolac, which significantly increased arteriolar vasodilation in the first 30 min of reperfusion and significantly reduced the I-R-induced vasoconstriction in arterioles at 30 min; this effect was lost at 1 hr of reperfusion. Although ketorolac augments immediate arteriole vasodilation and blocks subsequent vasoconstriction, this effect appears to be transient. These findings suggest that ketorolac may have potential as a treatment for I-R injury.

A multicenter comparison of the ocular efficacy and safety of diclofenac 0.1% solution with that of ketorolac 0.5% solution in patients with acute seasonal allergic conjunctivitis

Only one of several available ophthalmic nonsteroidal anti-inflammatory drugs (NSAIDs) is currently FDA approved for use in acute seasonal allergic conjunctivitis (SAC). Sixty patients with SAC and moderate itching and bulbar conjunctival injection were enrolled in a multicenter, randomized, double-masked, parallel-group trial comparing diclofenac sodium (DS) with ketorolac tromethamine (KT). Patients instilled 1 drop four times daily while awake for 14 days. Ocular signs and symptoms were evaluated at one and two weeks. The primary efficacy variables were itching and bulbar conjunctival injection. For both treatments, the ocular allergy sign and symptom scores were comparable at baseline. Both treatments evaluated in this study were well tolerated. Significant clinical and statistical reductions from baseline were observed in the primary efficacy variables. Treatment group differences were observed for the pain/soreness score with an advantage observed for the DS group at 30 minutes and at day 7. Our conclusion is that diclofenac sodium and ketorolac tromethamine acted similarly to reduce the ocular signs and symptoms associated with acute seasonal allergic conjunctivitis. There was a statistically significant advantage for the DS group to be free of symptoms at the day 7 visit as compared to the KT group (20.7% vs. 3.2%).

Analgesic efficacy and safety of nonpreserved ketorolac tromethamine ophthalmic solution following radial keratotomy. Ketorolac Radial Keratotomy Study Group

PURPOSE

To compare the analgesic efficacy and safety of nonpreserved ketorolac tromethamine 0.5% with those of its vehicle in the treatment of postsurgical ocular pain following radial keratotomy.

METHODS

This study employed a multicenter, double-masked, randomized, parallel-group design. Radial keratotomy patients were treated with either nonpreserved ketorolac tromethamine 0.5% or its vehicle four times daily for up to 3 days following surgery. Patients were provided with an escape medication (acetaminophen) for use only as needed for intolerable pain.

RESULTS

Patients treated with ketorolac reported significantly greater pain relief (P < or =.023), less pain intensity (P < or =.047), less use of escape medication (P < or =.001), fewer symptoms of ocular discomfort (P=.024), and fewer sleep disturbances (P < or =.013) than did patients treated with vehicle. No treatment-related adverse events were reported in the ketorolac group, and only one treatment-related adverse event was reported in the vehicle group. Most other safety findings were equivalent in the two treatment groups except that there were significantly less eyelid erythema (P=.026) and eyelid edema (P < or =.001) in the ketorolac group.

CONCLUSIONS

Nonpreserved ketorolac tromethamine 0.5% ophthalmic solution was significantly more effective than, and as safe as, vehicle in the treatment of postoperative pain associated with radial keratotomy. Therefore, topical ketorolac may be a valuable treatment option for the maintenance of patient comfort following refractive surgery.

Cystoid macular edema associated with cytomegalovirus retinitis in patients with the acquired immunodeficiency syndrome

PURPOSE

To describe the clinical and fluorescein angiographic appearance of cystoid macular edema associated with cytomegalovirus retinitis in patients with the acquired immunodeficiency syndrome (AIDS).

METHODS

We retrospectively examined the clinical and photographic records of four patients with AIDS and cytomegalovirus retinitis who developed cystoid macular edema.

RESULTS

Seven eyes of four patients with AIDS and cytomegalovirus retinitis experienced decreased vision associated with cystoid macular edema. Vitreous inflammation was mild in each patient. In all eyes, the retinitis involved zone 1, and in all but one eye, the cytomegalovirus retinitis was inactive. In one eye, the cystoid macular edema was worsened by formation of a dense juxtafoveal epiretinal membrane.

CONCLUSIONS

Although infrequently recognized, cystoid macular edema can cause visual loss in patients with AIDS and cytomegalovirus retinitis. Fluorescein angiography should be considered in any patient with cytomegalovirus retinitis and unexplained visual loss.

Prolonged central intravenous ketorolac continuous infusion in a cancer patient with intractable bone pain

OBJECTIVE

To report the case of a prolonged intravenous ketorolac continuous infusion given via a central line in a cancer patient with intractable bone pain.

CASE SUMMARY

A 56-year-old Hispanic man with stage IV non-small-cell lung cancer and multiple bone metastases was admitted to the hospital for intractable pain inadequately controlled at home by conventional therapy. He was treated with an intravenous continuous infusion of ketorolac 120 mg in 250 mL of NaCl 0.9% infused over 24 hours. The ketorolac was given via a central line for 14 days in addition to fentanyl patient-controlled analgesia. Over this time period the patient reported his pain to be well controlled. His requests for bolus doses of fentanyl decreased dramatically and the dose of the continuous intravenous fentanyl was reduced by 22%. In addition, the total daily dose of ketorolac was reduced following a change from intermittent bolus dosing to a continuous infusion.

DISCUSSION

The management of cancer pain secondary to bone metastasis is a difficult and challenging problem frequently encountered by the healthcare team. The use of nonsteroidal antiinflammatory drugs (NSAIDs) as adjuvant therapy is a common practice. However, many terminally ill patients are unable to take oral medications, thus limiting NSAID treatment options. Ketorolac tromethamine is approved by the Food and Drug Administration (FDA) as a parenteral NSAID. As with other NSAIDs, the risk of adverse drug reactions must be considered when using this class of medication. The FDA has approved ketorolac for the short-term (< or = 5 d) management of moderately severe acute pain that requires analgesia at the opioid level, usually in the postoperative setting. However, certain patients may benefit from long-term use exceeding the FDA-recommended guidelines of 5 days of maximum therapy.

CONCLUSIONS

A prolonged central intravenous ketorolac continuous infusion was successful in treating a cancer patient with intractable bone pain secondary to widely metastatic non-small-cell lung cancer.