Duration of Toradol therapy

[Farmercyst]

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I had an rx the other day for Toradol 1 qd prn #20. I've seen quite a couple patients on Toradol longer than the 5 day max. The one I dispensed was a patient had been on 3 mos of therapy and had switched PCPs. The new PCP had done LFTs and SCrs. Pt said was not getting sufficient relief from other NSAIDs and Narcotic side effects were bothersome at best. Is the risk of liver failure worse than the benefit of mobility in a patient with severe arthritis/spondylitis, etc?

 

[awval999]

It's not just liver failure though, GI bleeding, especially in the elderly will be problem.

In my opinion, it wouldn't be my drug of choice. So I would confirm and document. I may recommend Celebrex to the MD.

It's a risk/benefit situation obviously. If it's the only thing that helps severe arthritis/pain, then it is what it is.

 

[Carboxide]

I agree with awval. Not the drug of choice and it's dangerous for long-term use. I'd recommend Celebrex. Is the patient on a DMARD?

At minimum, the patient needs to be counseled on the potential side effects of taking this medication every day. Maybe they'll be fine with it; maybe they won't be and would rather take a less effective drug.

 

[deleted205891]

The maximum is 5 days or 20 doses I believe.

 

[rph3664]

I thought its use was restricted because of kidney issues.

 

[cycloketocaine]

I thought its use was restricted because of kidney issues.

NSAID's affect the kidneys. Ketorolac is special cause of its propensity to cause GI bleeds.

All the books say 5 days, but stuff is done off label all the time. I say just call and document, cover your azz, cause no one else will when someone gets a bleeding ulcer.

 

[lorain]

i call to double check and DOCUMENT

 

[Trent Steele]

explain the sitch to the MD, and let him know all the risks associated with the treatment.... theres no way hell still want to use it; if so, document the conversation and it will be out of your hands

 

[rph3664]

NSAID's affect the kidneys. Ketorolac is special cause of its propensity to cause GI bleeds.

That too, but Toradol seemed to be especially brutal to kidney function.

 

[PharmDstudent]

I worked on a Toradol protocol during a rotation in pharm school. No more than 5 days max. (Elderly patient was on it for 20 days and died of a gi bleed.)

 

[R2pharmD2]

I worked on a Toradol protocol during a rotation in pharm school. No more than 5 days max. (Elderly patient was on it for 20 days and died of a gi bleed.)

😱

I understand that the side effects of opiates are problematic for some patients (and this patient in particular) but would it make more sense to try and manage the side effects with additional medication if none of the alternative NSAIDs are dealing with the pain? Phenergan or zofran for the nausea, docusate for constipation, etc.?

 

[owlegrad]

What kind of pain is the pt experiencing?

 

[Farmercyst]

I agree with awval. Not the drug of choice and it's dangerous for long-term use. I'd recommend Celebrex. Is the patient on a DMARD?

At minimum, the patient needs to be counseled on the potential side effects of taking this medication every day. Maybe they'll be fine with it; maybe they won't be and would rather take a less effective drug.

Last I checked, Celebrex's long term safety data isn't much better than other NSAIDs. Also, isn't Toradol the only NSAID indicated for moderate-severe pain? Aren't the others just for mild-moderate pain?

As for duration of therapy, this particular person had at least 6 refills in her profile prior to me even looking at it. The caretaker was picking it up (not sure if paid or family member) and I went over the many possible side effects. The caretaker felt this was the only thing providing her sufficient relief. I'd have to go back into her profile to see if she's got other DMARDs on board. It's been ~2weeks since she filled. I'd have to search to find it. I'll see if I can find it and get more info.

 

[Farmercyst]

What kind of pain is the pt experiencing?

The way it was explained to me, it sounded like rheumatoid arthritis with hip/knee involvement and possibly spine as well.

 

[Farmercyst]

NSAID's affect the kidneys. Ketorolac is special cause of its propensity to cause GI bleeds.

That too, but Toradol seemed to be especially brutal to kidney function.

Fulminant hepatic necrosis comes to mind.

 

[Carboxide]

Last I checked, Celebrex's long term safety data isn't much better than other NSAIDs. Also, isn't Toradol the only NSAID indicated for moderate-severe pain? Aren't the others just for mild-moderate pain?

As for duration of therapy, this particular person had at least 6 refills in her profile prior to me even looking at it. The caretaker was picking it up (not sure if paid or family member) and I went over the many possible side effects. The caretaker felt this was the only thing providing her sufficient relief. I'd have to go back into her profile to see if she's got other DMARDs on board. It's been ~2weeks since she filled. I'd have to search to find it. I'll see if I can find it and get more info.

I'd agree that Celebrex has similar side effects. The reason why I'd say it might be better (and keep in mind that I'm a student, so this isn't from any clinical experience) is that the rate of GI bleeds is lower. According to Micromedex, the risk of GI hemorrhage and perforations are both less than 0.1% for celecoxib. For Toradol, they're both between 1 and 10%. That's a 10 to 100fold difference - pretty significant IMO.

I'd be curious to see what side effects of the narcotics the patient finds intolerable. If it's sedation/mental status, not much can be done, but otherwise perhaps there's something that could be combined to limit that. I mean...I don't love the idea of using a drug to counteract the side effects of another drug. But in this case, it seems like this patient is in serious danger of GI bleed.

 

[Rockinacoustic]

Bumping this thread for more discussion with an emphasis on inpatient use. What are y'all doing to prevent toradol use > 5 days in patients NPO to spare opioid use? IV APAP or IV ibuprofen? Permitting > 5 days use in certain scenarios?

 

[gwarm01]

Bumping this thread for more discussion with an emphasis on inpatient use. What are y'all doing to prevent toradol use > 5 days in patients NPO to spare opioid use? IV APAP or IV ibuprofen? Permitting > 5 days use in certain scenarios?

IV APAP has been pretty common in my experience. I work in peds so I usually only see IV ibuprofen in neonates.

 

[BidingMyTime]

There is a reason Toradol has been taken off the market in several countries, the risk of death isn't worth continuing past the 5 days maximum.

 

[Farmercyst]

There is a reason Toradol has been taken off the market in several countries, the risk of death isn't worth continuing past the 5 days maximum.

Never have been able to find data on recurrent use. Is it 5 days per week, month, year, lifetime?

 

[BidingMyTime]

Never have been able to find data on recurrent use. Is it 5 days per week, month, year, lifetime?

5 days consecutive.....I'm not aware of any official recommendations on the minimum length of time needed between 5 day courses....presumably, the longer the better.

 

[Niosh]

Bumping this thread for more discussion with an emphasis on inpatient use. What are y'all doing to prevent toradol use > 5 days in patients NPO to spare opioid use? IV APAP or IV ibuprofen? Permitting > 5 days use in certain scenarios?

We have a 3 dose limit standard order on our hips/knees. If the patient really likes/benefits from it they can get a second 3 dose limit. Once one got the full 5 day limit, but ended up not using any on the 5th day. From there they go to IV APAP or PO APAP/ibuprofen.

 

[Dred Pirate]

We have a 3 dose limit standard order on our hips/knees. If the patient really likes/benefits from it they can get a second 3 dose limit. Once one got the full 5 day limit, but ended up not using any on the 5th day. From there they go to IV APAP or PO APAP/ibuprofen.

we do 5 days max - then have to go to IV APAP - but personally I have seen very few cases where the patient couldn't handle low dose opiods or where strict NPO and we couldn't find other options,

 

[Carboxide]

Bumping this thread for more discussion with an emphasis on inpatient use. What are y'all doing to prevent toradol use > 5 days in patients NPO to spare opioid use? IV APAP or IV ibuprofen? Permitting > 5 days use in certain scenarios?

We have a flat 5 day rule and a tracking program that catches it for us. It also catches wrong dosing. It is not negotiable.

IV APAP is a waste of money. We don't carry it and I have no desire to get it. If patient is not able to take ANY orals after 5 days of ketorolac therapy then they're either getting an enteral tube or TPN, and if they don't get a tube then it's probably fine to give them some prn narcs, or you can do rectal Tylenol.

We only use IV ibu for babies who have that cardiac whatever that I know nothing about. We almost never use it.

Our formulary has worked well for us. I would go to war over adding IV tylenol or ibu to formulary.

 

[BidingMyTime]

Our formulary has worked well for us. I would go to war over adding IV tylenol or ibu to formulary.

This. I'm not saying there is never a reason to use IV tylenol or ibu, but I believe part of the reason neither was invented until the past 10 years, was that there really was no need for either.

 

[zelman]

This. I'm not saying there is never a reason to use IV tylenol or ibu, but I believe part of the reason neither was invented until the past 10 years, was that there really was no need for either.

I think they're only new in the USA.

 

[trailerpark]

I'm also curious how many days should be in between more than one 5 day Toradol courses?


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[Carboxide]

I APAP really isn't that expensive... Like $30/vial. It's nice to have with some restrictions

What do you consider cheap?

$120 a day for a waste of time drug is a lot of money. That adds up quick. $30 is three bags of vanco...six of pip/taz...

 

[gwarm01]

What do you consider cheap?

$120 a day for a waste of time drug is a lot of money. That adds up quick. $30 is three bags of vanco...six of pip/taz...

Why do you consider it a waste of time drug? I've never read any studies on it, my experience with the drug has solely been order verification/drug dispensing. Is it just not that effective?

 

[njac]

This. I'm not saying there is never a reason to use IV tylenol or ibu, but I believe part of the reason neither was invented until the past 10 years, was that there really was no need for either.

As far as I'm concerned, other than neutropenic patients, that's what suppositories are for.

When someone does a study that shows me iv APAP is superior to pr APAP we can talk.

We do allow it X1 dose in PACU here, but we've got it on lockdown.


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[Carboxide]

There is a study that a one time dose of IV APAP decreases the amount of narcotics kids need.... I believe it was significant v oral APAP.

It is useful in febrile neutropenic pts who can't get rectal and are visiting and can't get an oral dose and can't have tordal

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There is a small study that showed it had a limited advantage in opioid-sparing effect after cardiothoracic surgery - something like 4 mg IV morphine over 24 hours. I haven't seen any evidence to show that the effect is anything beyond slightly limiting opioid usage. The clinical outcomes have no difference between groups in any actual clinical factor. There's no good reason to care about 4 mg morphine, especially in a patient that just had cardiothoracic surgery. Just give him some oxycodone, seriously. We give it to the guy with a two inch lac on his arm, but we all the sudden feel the need to limit the amount of opioid usage in patients s/p major surgery?

Re febrile neutropenia management: guidelines recommend we actively avoid masking fever in admitted febrile neutropenia patients.We need to know if they are febrile and to what degree.

Why do you consider it a waste of time drug? I've never read any studies on it, my experience with the drug has solely been order verification/drug dispensing. Is it just not that effective?

Because it's really expensive ($30/vial) and it's not very useful. If the patient absolutely can't take enterals, and absolutely can't take rectals, and absolutely can't have ketorolac, then just give them some damn opioids. If they can't tolerate any opioids at all, give them some ketamine with a little dose of midazolam as a kicker. The number of patients that would fail all of the above drugs is phenomenally low. If you have a truly special unique situation, which should be almost never, then have the team go through whatever your non-formulary approval process is and they can get some in for that patient only as a non-formulary drug.

 

[Rockinacoustic]

Appreciate all the responses!