IV Toradol

[OZ88]

IV Toradol? What has been the latest info on this route for Toradol? Is IV method safe to give with a NS flush?. Besides the renal insufficiency and GI bleed risk, are there any other risks that are cropping up to avoid this med. I hear that it is most usefull for post partum, pt's with allergies to narcs, musculo-skeletal trauma, some post op idications. What have others used it for and is it effective?

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[spyderdoc]

Works very well for ureteral colic...Expensive to use, so try to give PO NSAIDs when indicated...
IM=60mg
IV=30mg

 

[mikecwru]

Works very well for ureteral colic...Expensive to use, so try to give PO NSAIDs when indicated...
IM=60mg
IV=30mg

I like to use toradol for colicky pain (when the drug seeker doesn't given an allergy) but from everything I've seen, it holds no added benefit compared to ibruprofen. It also, IIRC, has an approx 24x risk of GI bleeding. There was an article from EM Abstract (I believe) that said that the commonly used IV dose of 30mg if way overboard, and that you can decrease GI bleeding and get the same efficacy with 10mg. I haven't seen an attending follow this, though, although I haven't really made an issue out of it.

But anecdotally, yes, people with real stones seem to get good relief from it.

mike

 

[docB]

I use Toradol a lot more infrequently than many of my colleagues. I think, based on what I've read, that it's essentially expensive Motrin with the risk of renal damage. I use it only for kidney stones IF the pt cant keep Motrin down.

 

[Katee80]

I use Toradol a lot more infrequently than many of my colleagues. I think, based on what I've read, that it's essentially expensive Motrin with the risk of renal damage. I use it only for kidney stones IF the pt cant keep Motrin down.

Do you give IV Torodol to pts who've taken say...over 1200 mg (give or take)of Naprosyn over a 58 hour period for pain control?

When is it ok to refuse MORE nsaids without getting "the look"?

You order only Motrin for kidney stones?!? Isn't that like the MOST painful s**t in the world? (next to child birth and open fractures)

 

[Seaglass]

It's OK to refuse more after you've already tried them all.

 

[Katee80]

It's OK to refuse more after you've already tried them all.

When you say all...do you mean ALL the nsaids or just the nap. and motrin? Doesn't the risk for bleeding increase with usage?

 

[OZ88]

How about for migraines? If fluid bolus or maxeran inneffective in past, would Toradol be a good alternative? There has been limited evidence in literature, but I hear of some success it reduces the migraine pain. Does the Toradol have risks with the IV route?

 

[docB]

Do you give IV Torodol to pts who've taken say...over 1200 mg (give or take)of Naprosyn over a 58 hour period for pain control?

When is it ok to refuse MORE nsaids without getting "the look"?

You order only Motrin for kidney stones?!? Isn't that like the MOST painful s**t in the world? (next to child birth and open fractures)

I meant in addition to narcotics. If they've alrady taken a bunch of NSAIDS I hold the Motrin and the Toradol and use just MS. My usual kidney stone cocktail is: NS 500cc bolus then 150 cc/hr, Motrin 800 po, phenergan 25 IV and MS 1-20 IV q 1 hour PRN pain. I can give my nurses a lot of leeway with the MS because they are good and can use an order like that to titrate to good relief.

 

[Seaglass]

Doesn't the risk for bleeding increase with usage?

I was just kiddin' with ya a bit. Seriously (and not for renal colic) when you are talking about NSAIDS you have to remember that although they have the same overall mechanism of action the actual molecular interactions/bioavailability/half-life, etc. are different and just because one doesn't work yyou shouldn't throw out the whole lot of 'em. Personally I am a big believer in 800mg ibuprofen for just about anything. Haven't seen many people get good relief with Naprosyn or the Cox 2's. Tylenol IMHO is only good for fever.

C

 

[SaltySqueegee]

I was just kiddin' with ya a bit. Seriously (and not for renal colic) when you are talking about NSAIDS you have to remember that although they have the same overall mechanism of action the actual molecular interactions/bioavailability/half-life, etc. are different and just because one doesn't work yyou shouldn't throw out the whole lot of 'em. Personally I am a big believer in 800mg ibuprofen for just about anything. Haven't seen many people get good relief with Naprosyn or the Cox 2's. Tylenol IMHO is only good for fever.

C

Seriously!

4 - 200mg IBs in the morning chased by a can of pepsi, and a slice of chocolate cake will cure any ailments or aches.

Side Effects - You may feel like a god that can shoot lightening from his fingertips, and/or feel like the mathematician in a Beautiful Mind ... "... OooooHHHhhh, I can see it all in my Mind's Eye! ... ..."

 

[Katee80]

How about for migraines? If fluid bolus or maxeran inneffective in past, would Toradol be a good alternative? There has been limited evidence in literature, but I hear of some success it reduces the migraine pain. Does the Toradol have risks with the IV route?

In my experience with migraine treatments ,10 mg Maxeran and 30 mg of Torodol with a bolus of NS and a narcotic to knock me out, work alright. After 72 hours though. Prior to that, I stay home and treat it myself with copious amounts of nsaids. Yummy. Some docs do ask how many nsaids I've taken and sometimes cut it out of the order. As for Torodol alone? Not for me but we're all different.

Now for a doctor's explanation......

 

[Katee80]

I meant in addition to narcotics. If they've alrady taken a bunch of NSAIDS I hold the Motrin and the Toradol and use just MS. My usual kidney stone cocktail is: NS 500cc bolus then 150 cc/hr, Motrin 800 po, phenergan 25 IV and MS 1-20 IV q 1 hour PRN pain. I can give my nurses a lot of leeway with the MS because they are good and can use an order like that to titrate to good relief.

I keep hearing about this Phenergan. You never hear about it up here. Here its Gravol and if that's not enough, well Ativan's always available.

What if the pt is allergic to MS? MS isn't ordered a lot here either. We're all about synthetics.

 

[Sheerstress]

There's an Annals article from 1996 (Vol. 28: 151-8) that compares IV Toradol and IV Demerol use in renal colic patients. They actually found that the Toradol superior in helping to alleviate pain, although this was at a dose (60 mg. IV) that would be unacceptable today.

Personally, I give IM or IV Toradol all the time for generalized musculskeletal pain and migraines (usually with Reglan and adequate hydration for the latter condition), and find that it works great. As long as you are screening out certain patients, e.g. bad PUD, renal failure patients, etc., and limiting the oral form to only five days (I write this on every prescription), Toradol is a great drug for a wide range of pain issues.

 

[Sessamoid]

I use IV ketorolac for ureterolithiasis as a first line, and practically not at all for anything else. I've never had them, but many describe it as the worst pain they've ever had in their lives. Given that level of pain, I'm generally inclined to go with the IV route both to decrease the time to pain relief, and to avoid the first pass effect. If a patient came in with severe pain from a crush injury or a fracture, do you give intravenous analgesia?

For musculoskeletal pain, I either use po or iv opioids, especially if I haven't ruled out a fracture yet. NSAIDs are relatively contraindicated in fractures due to delay in bone healing, according to many orthopods I've asked about it (and they did provide me with a copy of the study).

 

[Tenesma]

equianalgesic potency 30mg Toradol IV equals 10mg Morphine IV

 

[Sheerstress]

NSAIDs are relatively contraindicated in fractures due to delay in bone healing, according to many orthopods I've asked about it (and they did provide me with a copy of the study).

I believe it's only the older generation NSAIDS that affect bone healing over time. The COX-2 inhibitors, such as Celebrex and Vioxx, are supposed to be OK - correct me if I'm wrong.

 

[Sessamoid]

I believe it's only the older generation NSAIDS that affect bone healing over time. The COX-2 inhibitors, such as Celebrex and Vioxx, are supposed to be OK - correct me if I'm wrong.

Only study I could find was a lab study which measured bone healing in rat femur fractures +/- COX-2 inhibitor. Anybody else have better success in literature search?

 

[flighterdoc]

equianalgesic potency 30mg Toradol IV equals 10mg Morphine IV

My search and rescue team paramedics used to carry toradol for IV or IM, the doc pulled it a couple of years ago because it wasn't any more effective than oral nsaids?

Personally, I like the stuff - but when I'm drug seeking, I'm the one alergic to opioids so it confuses the hell out of ED staff.

 

[jwk]

Our PACU nurses love it - seems to work well for some orthopedic cases and laparascopic procedures as well, and they're disappointed if we didn't give it or don't order it.

That being said, I have never been that wild about it. I never thought it was the cure-all it was claimed to be. Some patients do well with it, some don't. The PO formulation causes lots of c/o belly pain.

We've stopped using it in ENT, plastics, and any other procedures where bleeding/oozing is a concern.

 

[ny skindoc]

As someone with a history of multiple visits to the ER for severe renal colic I can attest to the efficacy of IV Toradol especially when used in conjuction with meperidine.Also dramatic pain response to Dilaudid.If an ER doc tried to give me oral Motrin for this problem I would certainly tell him/her where to go!

 

[roja]

I've found that some of the best medicine for migraines is reglan and ivf. I was skeptical at first, without any kind of traditional 'pain' meds, but it works like a charm!

I use toradol for colicky pain and for that select class of patients that you know are not going ot be content with motrin but I don't want to give narcotics to.

Regarding using it for renal colic: there were several great trials for renal colic for demerol vs toradol, and toradol won. I can scroung up the refrences if you need them.

 

[docB]

As someone with a history of multiple visits to the ER for severe renal colic I can attest to the efficacy of IV Toradol especially when used in conjuction with meperidine.Also dramatic pain response to Dilaudid.If an ER doc tried to give me oral Motrin for this problem I would certainly tell him/her where to go!

If that's your attitude stay home and treat yourself. Motrin and Toradol work the same but Toradol is more dangerous and more expensive. Demerol and Dilaudid are euphorics that get people high which is why they are so popular. Some people feel that they can only get relief from something IV but that's just psychogenic. I'll stick by my regimine of Motrin, IV morphine (plenty of it) and phenergan or Zofran for the nausea.

 

[Sessamoid]

If that's your attitude stay home and treat yourself. Motrin and Toradol work the same but Toradol is more dangerous and more expensive. Demerol and Dilaudid are euphorics that get people high which is why they are so popular. Some people feel that they can only get relief from something IV but that's just psychogenic. I'll stick by my regimine of Motrin, IV morphine (plenty of it) and phenergan or Zofran for the nausea.

Most people who've had kidney stones describe it as the most painful thing they've ever experienced, even those who've had pretty painful experiences (e.g. childbirth). I'm generally inclined to use IV analgesia for that level of pain. Motrin theoretically should work just the same as ketorolac for renal colic, but there's no science to back that up yet. The few studies I could find on NSAIDs for renal colic suggest that not all NSAIDs are equivalent for this application.

Opiates are not quite useless for renal colic in my experience, but close. I've used doses of morphine that would have made me apneic on renal colic patients who reported nearly no relief whatsoever.

Plus, worrying about the cost of IV ketorolac in the same paragraph as suggesting Zofran for nausea just seems odd. As you can probably tell, I'm a great fan of IV ketorolac for renal colic, and I will be until something better comes along.

 

[Sessamoid]

I'm bringing up this topic again because I discovered something I didn't know. I had heard from European colleagues that they've successfully used indomethacin IV for treatment of acute renal colic, but had been under the impression that this formulation wasn't available in the United States. That impression was mistaken apparently, as this FDA web site shows. Anybody know about the dosing of this stuff for acute renal colic? It's certainly got a better safety profile than ketorolac.

edit: a couple studies I found used 50mg or 100mg of indocin iv for renal colic.

 

[docB]

Plus, worrying about the cost of IV ketorolac in the same paragraph as suggesting Zofran for nausea just seems odd. As you can probably tell, I'm a great fan of IV ketorolac for renal colic, and I will be until something better comes along.

I have found that those who don't get relief with MS don't get it from anything other than a euphoric. I use phenergan primarily and Zofran as a back up or if I don't yet know pregnancy status. Zofran would actually be my 3d line behind Inapsine if it were still available.

 

[Katee80]

I have found that those who don't get relief with MS don't get it from anything other than a euphoric. I use phenergan primarily and Zofran as a back up or if I don't yet know pregnancy status. Zofran would actually be my 3d line behind Inapsine if it were still available.

I have a question. My mother and I have both discovered that we do not respond to MS , T3 or plain codeine....at all.(just get sick) T3 doesn't work any better than extra strength tylenol only I get sore and achy all over as well. Is this wierd or does it happen? My prof says some people don't absorb MS or codeine very well and thats when things get complicated regarding pain treatment.

Never got euphoric from dilaudid or anything else for that matter.

Ever hear of it? And I'm not talking about the drugseeker allergic to all drugs other than drug of choice either.


Torodol's great but if extra is needed? Would you go with an opiate?

 

[Sessamoid]

I have found that those who don't get relief with MS don't get it from anything other than a euphoric. I use phenergan primarily and Zofran as a back up or if I don't yet know pregnancy status. Zofran would actually be my 3d line behind Inapsine if it were still available.

Are we still talking about renal colic here? Ketorolac has been shown in multiple trials to beat the hell out of any opiate for pain relief in renal colic. There's been no study of ibuprofen that I know of in the treatment of renal colic. Should work similarly in theory, but there's no science supporting it currently.

If you're looking for an antiemetic safe in pregnancy, metoclopramide should be your first choice, since it's a class B. Phenergan and compazine are both class C, but every Ob I've ever known uses it liberally in pregnant patients of all trimesters. Zofran's a wonder drug when nothing else works though.

 

[docB]

I have a question. My mother and I have both discovered that we do not respond to MS , T3 or plain codeine....at all.(just get sick) T3 doesn't work any better than extra strength tylenol only I get sore and achy all over as well. Is this wierd or does it happen? My prof says some people don't absorb MS or codeine very well and thats when things get complicated regarding pain treatment.

Never got euphoric from dilaudid or anything else for that matter.

Ever hear of it? And I'm not talking about the drugseeker allergic to all drugs other than drug of choice either.

I'm not sure exactly what your question is here. I gather that you are seeking validation for your personal situation in which you require Demerol for your migraines. As I've stated before, I err on the side of treating pain even if it means giving seekers more dope. I firmly believe that Demerol and Dilaudid are not good drugs because of their abuse potentials and the behavior that they cause. If your opiate receptors differ from those of the general population I'm sorry. It will be difficult for you to get pain relief as quickly as someone who can take MS.

Torodol's great but if extra is needed? Would you go with an opiate?

As I've stated, I always treat stones with opiates. I use MS. I never treat stones with NSAIDS alone.

 

[docB]

Are we still talking about renal colic here? Ketorolac has been shown in multiple trials to beat the hell out of any opiate for pain relief in renal colic. There's been no study of ibuprofen that I know of in the treatment of renal colic. Should work similarly in theory, but there's no science supporting it currently.

Then chalk it up to personal preference.

 

[Katee80]

I'm not sure exactly what your question is here. I gather that you are seeking validation for your personal situation in which you require Demerol for your migraines. As I've stated before, I err on the side of treating pain even if it means giving seekers more dope. I firmly believe that Demerol and Dilaudid are not good drugs because of their abuse potentials and the behavior that they cause. If your opiate receptors differ from those of the general population I'm sorry. It will be difficult for you to get pain relief as quickly as someone who can take MS.


As I've stated, I always treat stones with opiates. I use MS. I never treat stones with NSAIDS alone.

No I'm not seeking validation for demerol and migraines. That's a non issue right now. Just plain old wondering if anyone heard of this? Some reactions are classified as merely sensitivity reactions ,whereas some are full blown allergic reactions. I guess to reword my question....is this an allergy or not?

Thought I'd ask since my mom seems to be in the same boat.

 

[Sessamoid]

It's possible you metabolize morphine faster than most or just don't absorb it well. That first pass effect can be a killer.

As far as codeine goes, it's so weak as to be pretty much useless as a pain medication. I almost never prescribe Tylenol #3. If they have real pain, I generally use real pain medicine. I think Tylenol is highly underrated as a pain medication however, and I keep wondering when the hell we're going to get the IV form approved here in the United States.

 

[docB]

It's possible you metabolize morphine faster than most or just don't absorb it well. That first pass effect can be a killer.

As far as codeine goes, it's so weak as to be pretty much useless as a pain medication. I almost never prescribe Tylenol #3. If they have real pain, I generally use real pain medicine. I think Tylenol is highly underrated as a pain medication however, and I keep wondering when the hell we're going to get the IV form approved here in the United States.

I agree that codeine is useless. I never prescribe it unless the pt requests it. Ditto for darvocet.

My understanding is that we'll never get paracetamol here because it would still have to go through full FDA program (>$250 million) yet would hit the market as a generic. Consequently no drug company will do this.