Intra-articular joint injection with Ketorolac

[soccrwz]

link

Economic Impact of Ketorolac vs Corticosteroid Intra-Articular Knee Injections for Osteoarthritis: A Randomized, Double-Blind, Prospective Study

Pain relief was similar between ketorolac and corticosteroid injections. Ketorolac knee injection is safe and effective with a cost savings percentage difference of 143% when compared with corticosteroid.

Ultrasound guided intra-articular ketorolac versus corticosteroid injection in osteoarthritis of the hip: a retrospective comparative study - PubMed

The treatment of osteoarthritis of the hip with intra-articular ketorolac injection is as effective as that with intra-articular corticosteroid injection. Intra-articular ketorolac injection can be considered useful for patients with contraindications to using corticosteroids.

www.ncbi.nlm.nih.gov

Ultrasound guided intra-articular ketorolac versus corticosteroid injection in osteoarthritis of the hip: a retrospective comparative study.
Park KD1, Kim TK, Bae BW, Ahn J, Lee WY, Park Y.

The treatment of osteoarthritis of the hip with intra-articular ketorolac injection is as effective as that with intra-articular corticosteroid injection. Intra-articular ketorolac injection can be considered useful for patients with contraindications to using corticosteroids.
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Local Pain doc said he has been doing ketorolac IA joint injections with similar results to using steroids, anyone heard of this or doing it?

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[SommeRiver]

No but we used it in ganglion, scars, and neuroma injxns all the time in fellowship.

 

[Dr. Ice]

Been using for years in bad diabetics or in patients who don’t tolerate roids well for other reasons. Don’t think it works as well or as long but it’s not bad

 

[bronchospasm]

Use both Ketorolac30 mg and steroid with decent results.

 

[Ducttape]

be careful with both studies.

showing no difference between ketorolac and corticosteroids does not mean that ketorolac is beneficial. i dont think doing a study and looking for a lack of statistical significance makes much sense either. proving the Null hypothesis...

Listen to the data when results are not significant - PMC

Unexpected non-significant results from randomised trials can be difficult to accept. Catherine Hewitt, Natasha Mitchell, and David Torgerson find that some authors continue to support interventions despite evidence that they might be harmful

www.ncbi.nlm.nih.gov

A trial with statistically significant negative results should, generally, overwhelm any preconceptions and prejudices of the trialists. However, negative results that are not statistically significant are more likely to be affected by preconceived notions of effectiveness, resulting in interpretive bias. This interpretive bias may lead authors to continue to recommend interventions that should be withdrawn.

 

[soccrwz]

be careful with both studies.

showing no difference between ketorolac and corticosteroids does not mean that ketorolac is beneficial. i dont think doing a study and looking for a lack of statistical significance makes much sense either. proving the Null hypothesis...

Listen to the data when results are not significant - PMC

Unexpected non-significant results from randomised trials can be difficult to accept. Catherine Hewitt, Natasha Mitchell, and David Torgerson find that some authors continue to support interventions despite evidence that they might be harmful

www.ncbi.nlm.nih.gov

I get what your saying, but unfortunately they are both generic meds, so I doubt there is much research money going towards superiority studies. I wasn't able to find other studies, but I am sure they are out there, as I don't have access to a large databases anymore. The first looks at economic costs, and the second is a noninferiority. EBM doesn't state everything has to be a multicentered double blinded large study, just the best available.

For those brittle diabetics, osteoportic people, neck/back shoulder patients who receive multiple steroid injections, would we be better off just not using steroids. Of course you discuss the data with patients before trialing it, but have others found benefit, or have better data? I had never heard pure ketorolac without steroids before, sounded interesting for the applicability above.

 

[painfree23]

Oh wow, I haven’t really heard of this, but if patient is bad diabetic usually their kidneys suck too, so it’s ok to inject ketorolac?

 

[Ducttape]

free of charge is always Home - PubMed - NCBI

 

[soccrwz]

free of charge is always Home - PubMed - NCBI

Pubmed does not equal full text, most of the time you only have abstracts, and have to refer outside to obtain the entire report, which is what I was saying earlier

Im really just trying to get the best available information including clinical experience, I had never heard of it being used solely as an injectate, piqued my interest, especially in light of trying to reduce overall steroid doses for my older patients

 

[Ducttape]

pubmed provides the biggest amount of information. also less likely to get bias from one major organization.

if you choose not to look at level 1 or level 2 studies, you need to remember how weak the evidence is. ie level 3, 4 or 5 "studies" should not be your standard for deciding on therapeutic decisions. and in all reality I personally find it very difficult to post such information for others to view.

 

[soccrwz]

pubmed provides the biggest amount of information. also less likely to get bias from one major organization.

if you choose not to look at level 1 or level 2 studies, you need to remember how weak the evidence is. ie level 3, 4 or 5 "studies" should not be your standard for deciding on therapeutic decisions. and in all reality I personally find it very difficult to post such information for others to view.

I don't disagree that the best evidence is what we should use. I submit to you that I am not able to find significantly better evidence, including Level 1 evidence, nor will you find it for all SCS. Are these home run studies, no. That is why I am asking the experts here to see what the thought process among colleagues are, please do not be an academic purist, I asking for guidance/help from other pain docs to see if its reasonable or unreasonable...

 

[Ducttape]

Level V evidence is what you are asking for. no need to post studies. ask people about their personal experiences and some people will answer.


then I, as close to being a purist as anyone on the board, will post articles, and feel free to denigrate them.

fwiw, if the studies you post show no difference.... and there are studies out there that show that intraarticular steroid injections show no difference over placebo, that kind of downplays the likelihood that intraarticular ketorolac would help.

but that needs to be studied...

 

[soccrwz]

Level V evidence is what you are asking for. no need to post studies. ask people about their personal experiences and some people will answer.


then I, as close to being a purist as anyone on the board, will post articles, and feel free to denigrate them.

fwiw, if the studies you post show no difference.... and there are studies out there that show that intraarticular steroid injections show no difference over placebo, that kind of downplays the likelihood that intraarticular ketorolac would help.

but that needs to be studied...

I post studies because that is a higher level of evidence then one guy saying I've been doing xyz. Feasibility and noninferior studies precede superiority studies, as you know. If we are being academic purist should we only use Nevro. Abandon steroids in epidurals and just use PFNS and/or lidocaine like Lax advocates. Or abandon kyphoplasties because of the BMJ article, or RFA because of mint? I'm assuming all you recommend is PT? Well that has not been shown to reduce pain either and they reviewed it at ASRA. I'm obviously being facetious, and I know your a good doc. What I am getting at here is there are plenty of studies that show negative finds for what we do, there are considerable bias associated with all studies.

My point remains we know steroids have a whole host of side-effects, and we try to reduce the frequency and dose, is there another option beside IA steroid injections, thats what I am trying to elucidate, and is it reasonable to pursue that option for labile diabetics who have osteoporosis that are reaching their steroid limit, that is what I am trying to discover by asking the question, or spur debate saying the risks outweigh the benefit. Thus far I have not shown studies showing they are inferior, and at the risk of the only option being TKA we need to look at other options before going toward geniculates which many insurances don't cover unfortunately.

 

[callmeanesthesia]

PubMed

PubMed® comprises more than 38 million citations for biomedical literature from MEDLINE, life science journals, and online books. Citations may include links to full text content from PubMed Central and publisher web sites.

www.ncbi.nlm.nih.gov

“CONCLUSION: In vitro exposure of chondrocytes to single-dose equivalent concentrations of either ketorolac or meperidine demonstrated significant chondrotoxicity, while exposure to morphine or fentanyl did not lead to increased cell death.”

 

[soccrwz]

PubMed

PubMed® comprises more than 38 million citations for biomedical literature from MEDLINE, life science journals, and online books. Citations may include links to full text content from PubMed Central and publisher web sites.

www.ncbi.nlm.nih.gov

“CONCLUSION: In vitro exposure of chondrocytes to single-dose equivalent concentrations of either ketorolac or meperidine demonstrated significant chondrotoxicity, while exposure to morphine or fentanyl did not lead to increased cell death.”

Can you post the complete article? It seems like they were continuously infusion meds "A custom bioreactor was used to constantly deliver medications," which we don't do. What doses are these--0.3% and 0.6% ketorolac tromethamine?

 

[Ducttape]

I post studies because that is a higher level of evidence then one guy saying I've been doing xyz. Feasibility and noninferior studies precede superiority studies, as you know. If we are being academic purist should we only use Nevro. Abandon steroids in epidurals and just use PFNS and/or lidocaine like Lax advocates. Or abandon kyphoplasties because of the BMJ article, or RFA because of mint? I'm assuming all you recommend is PT? Well that has not been shown to reduce pain either and they reviewed it at ASRA. I'm obviously being facetious, and I know your a good doc. What I am getting at here is there are plenty of studies that show negative finds for what we do, there are considerable bias associated with all studies.

My point remains we know steroids have a whole host of side-effects, and we try to reduce the frequency and dose, is there another option beside IA steroid injections, thats what I am trying to elucidate, and is it reasonable to pursue that option for labile diabetics who have osteoporosis that are reaching their steroid limit, that is what I am trying to discover by asking the question, or spur debate saying the risks outweigh the benefit. Thus far I have not shown studies showing they are inferior, and at the risk of the only option being TKA we need to look at other options before going toward geniculates which many insurances don't cover unfortunately.

while there are many studies that show no effect or ill effects, there are also many studies that show short term benefit.

the studies that have shown benefit for chronic knee pain - there is some evidence for geniculars. there is evidence for weight loss.

you ask a good question. I'm just not sure the initial approach is effective or the most apropos. you may have your answer though - I don't see anyone posting that they are using toradol instead of steroids for these knee injections.

that would be a good study for you to do...