IM toradol and blood thinners

[GottaHaveIt]

Do you guys give patients these shots in the office if the patient is on plavix or other antiplatelet medications?

What about anticoagulants?

I don't but wanted to see what you all are doing.

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[lobelsteve]

I do and I do it often.

 

[painfree23]

U

Do you guys give patients these shots in the office if the patient is on plavix or other antiplatelet medications?

What about anticoagulants?

I don't but wanted to see what you all are doing.

Having them hold anticoagulant for toradol shot seems sort of ridiculous

 

[Ducttape]

not on patients on anticoagulation, but otherwise i use a lot of toradol.

 

[deleted875186]

I would give a one Toradol shot on Plavix or blood thinners. One dose is not going to make an ulcer.

 

[deleted875186]

Somewhat related.

I tell people on anticoagulation to use Voltaren. I searched and could not find a single case report of bleeding or ulcer thought to be from voltaren. Others thoughts?

 

[cowboydoc]

Somewhat related.

I tell people on anticoagulation to use Voltaren. I searched and could not find a single case report of bleeding or ulcer thought to be from voltaren. Others thoughts?

Use it heavily, particularly in this population.

 

[RoloTomassi]

Somewhat related.

I tell people on anticoagulation to use Voltaren. I searched and could not find a single case report of bleeding or ulcer thought to be from voltaren. Others thoughts?

Isn't Celebrex more selective, less bleeding issues than Voltaren?

 

[lobelsteve]

Isn't Celebrex more selective, less bleeding issues than Voltaren?

I think he meant topical only.

 

[strike5858]

How often are you guys giving toradol injections per patient? Any limit like 3-4 times a year? There are patients that would want it every month if they had their way.

I definitely underutilize it though.

 

[Sooshi]

According to my patients, Toradol is magical, cures all ailments, and lasts longer than an RFA. At this point I'd be shocked if it didn't cure depression, halitosis, and erectile dysfunction, too.

 

[lobelsteve]

How often are you guys giving toradol injections per patient? Any limit like 3-4 times a year? There are patients that would want it every month if they had their way.

I definitely underutilize it though.

I put in standing orders. They can get it at nurse visit qmonthly if desired.

 

[painfree23]

I put in standing orders. They can get it at nurse visit qmonthly if desired.

How do u tell the pharmacy not to dispense more than 1 per month

 

[lobelsteve]

How do u tell the pharmacy not to dispense more than 1 per month

IM injections. If you are talking pills, #10 qd prn. Patient education.

 

[Ducttape]

i do IM injections but not if anticoagulated. can be up to once a month. patient can get a follow up appointments, but will on occasion set up an urgent appt to avoid urgent care visit for same.

i dont do oral toradol - too much gastric distress.

technically voltaren gel very low amount of systemic absorption. still possible. im reluctant to use on vasculopaths.

 

[deleted875186]

i do IM injections but not if anticoagulated. can be up to once a month. patient can get a follow up appointments, but will on occasion set up an urgent appt to avoid urgent care visit for same.

i dont do oral toradol - too much gastric distress.

technically voltaren gel very low amount of systemic absorption. still possible. im reluctant to use on vasculopaths.

What is the concern with vasculopaths with voltaren?

 

[Ferrismonk]

I will give IM toradol in office, during procedures, and will sometimes give Rx for IM toradol for patient to pick up at pharmacy and use on their own. Last one requires patient education and a willing to stab themselves.

I also don't give oral toradol.

For anticoagulated that need/want NSAID, I'll recommend Voltaren gel instead of PO.

 

[Ducttape]

What is the concern with vasculopaths with voltaren?

only that it is an antiinflammatory and oral antiinflammatory agents have been implicated with increased risk for recurrent cardiac and stroke events.

 

[Timeoutofmind]

only that it is an antiinflammatory and oral antiinflammatory agents have been implicated with increased risk for recurrent cardiac and stroke events.

I don’t prescribe any oral nsaids for this reason… even aside from the gastric and renal risks

If someone has any CKD I don’t do Voltaren gel as there is still about 5% topical absorption and it’s a further hit the kidneys. In a case I do compounded ketamine gel as it has some nociceptive as well as neuropathic coverage

 

[painfree23]

I don’t prescribe any oral nsaids for this reason… even aside from the gastric and renal risks

If someone has any CKD I don’t do Voltaren gel as there is still about 5% topical absorption and it’s a further hit the kidneys. In a case I do compounded ketamine gel as it has some nociceptive as well as neuropathic coverage

U think the topical voltaren gel is doing more damage on their kidneys than their blood pressure or A1c >8 or fried food for breakfast lunch and dinner?

 

[Ducttape]

no, but i would assume that you are not prescribing fried food, or anything purposefully that would increase their blood pressure or A1C.

one could argue about whether steroids should be used, however......


do no harm.

 

[deleted131481]

Anyone here do NSAIDs in ESRD? Still cardiac/GI effects but if kidneys are gone...

 

[painfree23]

Anyone here do NSAIDs in ESRD? Still cardiac/GI effects but if kidneys are gone...

I never understood why not in ESRD, but I don’t .

 

[jewwithguitar]

I do not currently offer IM Toradol, but I am intrigued. A few questions for those of you who offer it:

1. In which situations do you typically utilize it/find it most useful?

2. Do you avoid it if patient is taking/will be taking an oral steroid?

3. How are you billing it?

 

[Tramadeezy]

Toradol is great to have on hand in office. I tell patients if they are gonna go to the ER because their pain is so bad to come by the office instead for a shot. Saves them time/money.

 

[deleted875186]

Do people ever put 30mg toradol in their lumbar trigger point injections?

 

[deleted131481]

Do people ever put 30mg toradol in their lumbar trigger point injections?

yes. TPI with plain local or add some toradol. No steroid for mine.

 

[MitchLevi]

I always mix 15-60mg of Toradol into my TPI. Sicker, older pts will get 15mg, younger pts 60mg.

If I do a subacromial I'll intermittently add Toradol, same with greater trochanter. Not for any added benefit to the anatomy in question, and more for systemic effects.

Steroid and 2cc of local works great, but dropping 1cc of local in favor of 30mg Toradol is better. Try it.

"I'm hurting everywhere, but this left shoulder is awful." Toradol in the shot.

During fellowship, our program director put Toradol in SGB/LSB, which I thought was odd and in hindsight is typical academia without justification.

Older orthopedic surgeons will still occasionally put Toradol in their knee injxns, which I don't understand.

I think steroid in a TPI is dumb, and there are local PCPs who do it in my area. One 40 yo F pt of mine got "TPIs" with triamcinolone into her buttock and lumbar spine...Massive fat atrophy with a ping pong ball cavitation in the superior buttock. Terrible.

Edit - Someone asked about oral steroids. The medical establishment needs to quit with that. I bet I Rx no more than 5x per yr. A red hot nerve is the only time I do it, but it is wholly inconsistent and rarely changes the clinical course. Acute LBP...You can't escape an acute LBP visit with a mid-level in my area without a 5-7d Medrol pack or a 10d prednisone taper (I've seen 60mg QD tapered over 10 days for acute or acute on chronic axial LBP).

 

[lobelsteve]

I always mix 15-60mg of Toradol into my TPI. Sicker, older pts will get 15mg, younger pts 60mg.

If I do a subacromial I'll intermittently add Toradol, same with greater trochanter. Not for any added benefit to the anatomy in question, and more for systemic effects.

Steroid and 2cc of local works great, but dropping 1cc of local in favor of 30mg Toradol is better. Try it.

"I'm hurting everywhere, but this left shoulder is awful." Toradol in the shot.

During fellowship, our program director put Toradol in SGB/LSB, which I thought was odd and in hindsight is typical academia without justification.

Older orthopedic surgeons will still occasionally put Toradol in their knee injxns, which I don't understand.

I think steroid in a TPI is dumb, and there are local PCPs who do it in my area. One 40 yo F pt of mine got "TPIs" with triamcinolone into her buttock and lumbar spine...Massive fat atrophy with a ping pong ball cavitation in the superior buttock. Terrible.

Edit - Someone asked about oral steroids. The medical establishment needs to quit with that. I bet I Rx no more than 5x per yr. A red hot nerve is the only time I do it, but it is wholly inconsistent and rarely changes the clinical course. Acute LBP...You can't escape an acute LBP visit with a mid-level in my area without a 5-7d Medrol pack or a 10d prednisone taper (I've seen 60mg QD tapered over 10 days for acute or acute on chronic axial LBP).

Is Toradol in a tpi legitimate medical care?

63672 = .17 rvu
20552 = .66 rvu

Asking for a friend.

 

[MitchLevi]

Is Toradol in a tpi legitimate medical care?

63672 = .17 rvu
20552 = .66 rvu

Asking for a friend.

Are TPI legitimate medical care?

 

[lobelsteve]

Are TPI legitimate medical care?

Acceptable. Not terribly useful or efficacious. Would love to see them dropped from coverage and be cash pay at $10 per.

 

[MitchLevi]

Acceptable. Not terribly useful or efficacious. Would love to see them dropped from coverage and be cash pay at $10 per.

Are you asserting that my adding Toradol is somehow fraudulent or unacceptable medical care?

 

[lobelsteve]

Are you asserting that my adding Toradol is somehow fraudulent or unacceptable medical care?

I do not. But an auditor could down code you to IM injection of therapeutic agent. I do see that happening if the J code for Toradol pops up with every 20552.

 

[MitchLevi]

I do not. But an auditor could down code you to IM injection of therapeutic agent. I do see that happening if the J code for Toradol pops up with every 20552.

Here's to providing decent (but not perfect) medical care and living dangerously!

 

[DODOCSS]

I do not. But an auditor could down code you to IM injection of therapeutic agent. I do see that happening if the J code for Toradol pops up with every 20552.

Could be wrong, but you can inject Georgia peaches as long as it’s in the muscles

 

[lobelsteve]

Could be wrong, but you can inject Georgia peaches as long as it’s in the muscles

Health Lab

Test Name:	ALLERGEN - PEACH IgE (F95)
Test Code:	2120959
Alias:	LAB9760 Peach
CPT Code(s):	86003

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