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Stop giving 30 mg of ketorolac

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deleted171991


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Just another study which proves that ketorolac reaches most of its analgesic effects at 10 mg. I have been giving only 15 of ketorolac to everybody, regardless of age, for years.

https://pharmertoxguy.com/2016/12/16/the-ceiling-effect-of-iv-ketorolac/

http://www.annemergmed.com/article/S0196-0644(16)31244-6/fulltext
Results
We enrolled 240 subjects (80 in each dose group). At 30 minutes, substantial pain reduction was demonstrated without any differences between the groups (95% confidence intervals 4.5 to 5.7 for the 10-mg group, 4.5 to 5.6 for the 15-mg group, and 4.2 to 5.4 for the 30-mg group). The mean numeric rating scale pain scores at baseline were 7.7, 7.5, and 7.8 and improved to 5.1, 5.0, and 4.8, respectively, at 30 minutes. Rates of rescue analgesia were similar, and there were no serious adverse events. Secondary outcomes showed similar rates of adverse effects per group, of which the most common were dizziness, nausea, and headache.

Conclusion
Ketorolac has similar analgesic efficacy at intravenous doses of 10, 15, and 30 mg, showing that intravenous ketorolac administered at the analgesic ceiling dose (10 mg) provided effective pain relief to ED patients with moderate to severe pain without increased adverse effects.

Importance
Nonsteroidal anti-inflammatory drugs may commonly be used at doses above their analgesic ceiling, although this may not offer an incremental analgesic advantage and potentially adds risk of harm. Analgesic ceiling is the dose of a drug beyond which any further dosage increase results in no additional analgesic effect.4 The ketorolac analgesic ceiling dose of 10 mg is lower than both the dosing regimen recommended in emergency medicine textbooks5 and the recommended Food and Drug Administration–approved doses: 30 mg intravenously and 60 mg intramuscularly for patients younger than 65 years.6 Ketorolac is the only analgesic whose parenteral dosing is 3 to 6 times higher than the oral regimen based on the Food and Drug Administration–recommended oral regimen of 10 mg every 6 hours for no more than 5 days.6

Like all nonsteroidal anti-inflammatory drugs, ketorolac has several potentially serious adverse effects: gastrointestinal hemorrhage, nausea, vomiting, dyspepsia, dizziness or lightheadedness, and somnolence. Of these, gastrointestinal hemorrhage is the most concerning because it also appears to be dose dependent. Of all nonsteroidal anti-inflammatory drugs, the risk of gastrointestinal hemorrhage is highest for ketorolac and increases with higher doses.7 In healthy volunteers, single doses of parenteral ketorolac have been demonstrated to interfere with platelet function by prolonging bleeding time, inhibiting platelet aggregation, and reducing platelet thromboxane production.8, 9, 10 Likewise, single doses of ketorolac at 15 and 30 mg intravenously and 60 mg intramuscularly have been shown to worsen hemorrhage in postoperative patients.11, 12

Several studies have demonstrated that ketorolac analgesic efficacy at 10 mg is similar to that at higher doses (15 to 90 mg) for treatment of postoperative and cancer pain while minimizing the adverse effects typical of higher dosages.13, 14, 15, 16 Despite this, Food and Drug Administration recommendations and the majority of studies of parenteral ketorolac in the ED advocate the use of doses that are higher than 10 mg.
 
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Noyac

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I can remember back when I started anesthesia using 60mg. :uhno:

I have switched over to ibuprofen (caldolor) these days.
 

STLINI

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I'll admit to being ignorant on the Caldolor literature. Is it more effective that ketorolac? How much does it cost? We don't have it on formulary.
 

kidthor

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Whatever dose you use, it'll still make the patient exsanguinate and mess up bone healing.
 
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Hoya11

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sigrhoillusion

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Mman

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I've never ordered more than 15 mg for someone in my life. I recall seeing a dose finding study once that suggested as low as 5 mg was probably as effective as 60 mg. The only reason I order 15 instead of 5 or 10 is that it's easier to measure out 0.5 ml instead of 0.333 mls.
 

WholeLottaGame7

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urge

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Because it's there.
I also seems (subjective on my part) to work better than toradol.

I have a have a hard time believing that.

I bet it is a lot more expensive than toradol.
 

epidural man

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I remember seeing a chart that showed relative pain reduction and anti-inflammatory properties of all the NSAIDS (it may have been in a lecture from Tony Yaksh). If I recall, ketoralac isn't very anti-inflammatory, but worked better for pain reduction than ibuprofen.

However, ibuprofen works pretty well - but ketoralac maybe 10x cheaper?

pain NNT.jpg
 

urge

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I remember seeing a chart that showed relative pain reduction and anti-inflammatory properties of all the NSAIDS (it may have been in a lecture from Tony Yaksh). If I recall, ketoralac isn't very anti-inflammatory, but worked better for pain reduction than ibuprofen.

However, ibuprofen works pretty well - but ketoralac maybe 10x cheaper?

View attachment 212170
Where is ketorolac in that chart?
 
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Timeoutofmind

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I remember seeing a chart that showed relative pain reduction and anti-inflammatory properties of all the NSAIDS (it may have been in a lecture from Tony Yaksh). If I recall, ketoralac isn't very anti-inflammatory, but worked better for pain reduction than ibuprofen.

However, ibuprofen works pretty well - but ketoralac maybe 10x cheaper?

View attachment 212170
PO Celebrex is best maybe? No cox1 so doesn't thin the blood at all...
 

Scotty_G

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I stopped using 30mg after training :) Many providers/nurses ask me if I'm sure i only want to do 15mg lol
 
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deleted162650

Do you guys change dose based on body weight or BSA? Common sense tells me that 15mg is not the same to a 100kg 22yo bodybuilder as it is to a 50kg 65yo F.
 
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epidural man

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I have nothing to add - I'm just typing so I can continue to look at the YogaOutlet add on the bottom of my page. Are you all seeing that too?
 

Arcan57

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I remember seeing a chart that showed relative pain reduction and anti-inflammatory properties of all the NSAIDS (it may have been in a lecture from Tony Yaksh). If I recall, ketoralac isn't very anti-inflammatory, but worked better for pain reduction than ibuprofen.

However, ibuprofen works pretty well - but ketoralac maybe 10x cheaper?
That chart doesn't seem to jibe with my experience. Tylenol with codeine being more efficacious than 10mg of morphine IM? Was this in a population that had already had their opioid receptors saturated? Agree with dosing of ketorolac although the icing on the cake would be proving fewer side effects with the 15mg dose.
 
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Timeoutofmind

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That chart doesn't seem to jibe with my experience. Tylenol with codeine being more efficacious than 10mg of morphine IM? Was this in a population that had already had their opioid receptors saturated? Agree with dosing of ketorolac although the icing on the cake would be proving fewer side effects with the 15mg dose.
So people aren't doing PO Celebrex to avoid the cox1 bleeding issues? Makes sense to me...
 
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nimbus

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That chart doesn't seem to jibe with my experience. Tylenol with codeine being more efficacious than 10mg of morphine IM? Was this in a population that had already had their opioid receptors saturated? Agree with dosing of ketorolac although the icing on the cake would be proving fewer side effects with the 15mg dose.


But the first study said the incidence of adverse effects was similar in all 3 groups. This may be an example of paying attention to things that aren't important referred to in the thread about PP vs academics.
 

epidural man

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That chart doesn't seem to jibe with my experience. Tylenol with codeine being more efficacious than 10mg of morphine IM? Was this in a population that had already had their opioid receptors saturated? Agree with dosing of ketorolac although the icing on the cake would be proving fewer side effects with the 15mg dose.
If I recall, I think this comparative study was based on a single dose - pain reduction post surgery in opioid naïve patients - but not 100% sure that is where it comes from. it's been a long time since I gave the lecture that I pulled this chart from.
 

zizzer

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I still use 30mg for the longer duration unless I'm a little more concerned about adverse effects in a particular patient.

Relevant:

https://www.annemergmed.com/article/S0196-0644(17)31694-3/fulltext?code=ymem-site

"Ceiling Effect Is Not the Only Effect"

To the Editor:

I am concerned that the recent study by Motov et al purporting to show “similar analgesic efficiency” at 3 different doses of intravenous ketorolac and claiming to “provide a basis for changes in practice patterns and guidelines in ED [emergency department] care” may be misleading to clinicians using this common agent. The Editor’s Capsule Summary statement that “there is no benefit to using higher doses of ketorolac for pain relief…” is problematic. Simply put, the authors’ oft-repeated theme that there is a “ceiling” effect on the analgesic efficacy of the drug is not the only consideration. The duration of drug effect, or “the area under the curve,” a critically important issue in the treatment of acute pain, was never mentioned. Although the pharmacodynamics of ketorolac is a little complex (the 2 isomers have different half-lives), the relationship to dose is, in fact, linear. Increasing the minimally effective dose would greatly increase the duration of analgesic effect. So, for example, tripling the 10-mg dose to the Food and Drug Administration–recommended 30-mg dose would greatly increase the time that the ceiling concentration of the drug would be in effect. Instead of perhaps 4 hours (as the authors note, the half-life has considerable variability), it might be 12. The ED patient with a painful burn at 9 pm might not run out of analgesia until 9 am instead of at 1 am. It is difficult to understand how this translates to “no benefit.” The authors do concede that their study “did not assess whether higher doses may have resulted in prolonged pain relief beyond 120 minutes,” but both pharmacokinetic and clinical data leave no doubt that it does. Clinicians should understand that “ceiling effect” is only one factor in choosing an analgesic. The authors have clearly not succeeded in their stated goal of demonstrating that “higher doses (more than 10 mg) of ketorolac are superfluous.”
 
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anes121508

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i get strange looks when I give half the 30mg vial nearly twice a week

how are you guys using celebrex in your practice?
 

dchz

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I still use 30mg for the longer duration unless I'm a little more concerned about adverse effects in a particular patient.

Relevant:

https://www.annemergmed.com/article/S0196-0644(17)31694-3/fulltext?code=ymem-site

"Ceiling Effect Is Not the Only Effect"

To the Editor:

I am concerned that the recent study by Motov et al purporting to show “similar analgesic efficiency” at 3 different doses of intravenous ketorolac and claiming to “provide a basis for changes in practice patterns and guidelines in ED [emergency department] care” may be misleading to clinicians using this common agent. The Editor’s Capsule Summary statement that “there is no benefit to using higher doses of ketorolac for pain relief…” is problematic. Simply put, the authors’ oft-repeated theme that there is a “ceiling” effect on the analgesic efficacy of the drug is not the only consideration. The duration of drug effect, or “the area under the curve,” a critically important issue in the treatment of acute pain, was never mentioned. Although the pharmacodynamics of ketorolac is a little complex (the 2 isomers have different half-lives), the relationship to dose is, in fact, linear. Increasing the minimally effective dose would greatly increase the duration of analgesic effect. So, for example, tripling the 10-mg dose to the Food and Drug Administration–recommended 30-mg dose would greatly increase the time that the ceiling concentration of the drug would be in effect. Instead of perhaps 4 hours (as the authors note, the half-life has considerable variability), it might be 12. The ED patient with a painful burn at 9 pm might not run out of analgesia until 9 am instead of at 1 am. It is difficult to understand how this translates to “no benefit.” The authors do concede that their study “did not assess whether higher doses may have resulted in prolonged pain relief beyond 120 minutes,” but both pharmacokinetic and clinical data leave no doubt that it does. Clinicians should understand that “ceiling effect” is only one factor in choosing an analgesic. The authors have clearly not succeeded in their stated goal of demonstrating that “higher doses (more than 10 mg) of ketorolac are superfluous.”

Exactly this. I still give the 30mg because of the other effects and the low side effect profile.
 
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MoMoGesiologist

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Gave 15mg toradol in the OR once and the attending thought I was an idiot. 15...60mg... does it really matter in the end?
 

vector2

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I've swung back to giving 30mg of toradol to anyone <65 with normal kidney fnx who is at high risk for severe pain (open abd surgery without epidural etc). I think the duration argument with the higher dose from that letter to the editor is compelling.
 
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soccrwz

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https://www.openanesthesia.org/ketorolac_controversies/

FYI:

Data on Postoperative Hemorrhage Risk

Data Against Ketorolac: A retrospective post-marketing surveillance study of over 20,000 patients who received ketorolac or opioids showed a small, but statistically significant risk of gastrointestinal bleeding with ketorolac (OR=1.30, 95% CI=1.11–1.52) but no significant increased risk of surgical bleeding (odds ratio=1.02, 95% CI=0.95–1.10). (2)

Data on Bone Healing
Data Supporting Ketorolac:

While there is clearly a theoretic risk of impeded bone healing following surgery, it is not clear that these “theoretic” concerns have any clinical meaning. A study of 405 consecutive patients who underwent primary lumbar posterolateral intertransverse process fusion with pedicle screw instrumentation by one surgeon suggested that there was no difference between patients who did or did not receive ketorolac. (3)
 
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jthedestroyr

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Glad this is talked about again.

I quote those initial papers when I give lower doses. Our OBs use an insane amount of ketorolac though.

They give 30mg q6, yet intraop they "can see more bleeding instantly," if we give a one time dose of ketorolac. Always makes me laugh.
 
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epidural man

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https://www.openanesthesia.org/ketorolac_controversies/

FYI:

Data on Postoperative Hemorrhage Risk

Data Against Ketorolac: A retrospective post-marketing surveillance study of over 20,000 patients who received ketorolac or opioids showed a small, but statistically significant risk of gastrointestinal bleeding with ketorolac (OR=1.30, 95% CI=1.11–1.52) but no significant increased risk of surgical bleeding (odds ratio=1.02, 95% CI=0.95–1.10). (2)

Data on Bone Healing
Data Supporting Ketorolac:

While there is clearly a theoretic risk of impeded bone healing following surgery, it is not clear that these “theoretic” concerns have any clinical meaning. A study of 405 consecutive patients who underwent primary lumbar posterolateral intertransverse process fusion with pedicle screw instrumentation by one surgeon suggested that there was no difference between patients who did or did not receive ketorolac. (3)

The odds ratio for increased bleeding needs to consider age. The increased in bleeding was mostly seen in patients over 65.
 
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