Toradol and Lovenox

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jetproppilot

jetproppilot

Turboprop Driver
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15+ Year Member
Had a conversation today with an ortho buddy who believes toradol is contraindicated when Lovenox is being used.

For the premeds/early med students, Lovenox (enoxaparin) is a low molecular weight heparin commononly used postoperatively for DVT prophylaxis.

Anyone aware of any studies for or against Toradol useage when Lovenox is on board?

Thanks in advance.
 
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Here you go-your ortho buddy may be misinformed...

Ann R Coll Surg Engl. 1995 Jan;77(1):35-7.
Is there a clinical interaction between low molecular weight heparin and non-steroidal analgesics after total hip replacement?

Weale AE, Warwick DJ, Durant N, Prothero D.
Source

Taunton and Somerset Hospital, Musgrove Park.

Abstract

The benefits of parenteral non-steroidal analgesic drugs and low molecular weight heparin anticoagulants have been shown before, but there is concern that the use of these agents in combination may potentiate haemorrhagic side-effects because of simultaneous inhibition of the clotting cascade and platelet mechanisms of haemostasis. In a prospective controlled trial, 60 patients undergoing total hip replacement were randomised into two groups. Those in one group received intramuscular ketorolac and those in the other group opioid analgesia. All patients received enoxaparin subcutaneously, once daily. There were 34 patients in the NSAID group and 26 in the opiate group. There were no significant differences between the two groups for intraoperative blood loss, postoperative drainage, transfusion requirements, bruising, wound oozing and leg swelling. From this study it would appear that there is a low risk of significant haemostatic potentiation associated with concurrent use of low molecular weight heparin and a modest dose of ketorolac tromethamine.






jetproppilot said:
Had a conversation today with an ortho buddy who believes toradol is contraindicated when Lovenox is being used.

For the premeds/early med students, Lovenox (enoxaparin) is a low molecular weight heparin commononly used postoperatively for DVT prophylaxis.

Anyone aware of any studies for or against Toradol useage when Lovenox is on board?

Thanks in advance.
Click to expand...
 
Here's another one JPP...

Wait, sorry. Ahem, my name is D712. I am a premed. I used pubmed. My blood type is B+.

Ok.

Here's another one JPP:

J Lab Clin Med. 1996 Jun;127(6):583-7.
Interaction of low molecular weight heparin with ketorolac.
Green D, Klement P, Liao P, Weitz J.
Source
Department of Medicine, Northwestern University Medical School, Chicago, IL 60611, USA.

Abstract
Postoperative patients may receive ketorolac, a nonsteroidal antiinflammatory drug that inhibits platelet function, for analgesia and may receive low-molecular-weight heparin (LMWH) for thrombosis prevention. We investigated whether the combination of these two agents increases blood loss in a rabbit model of hemostasis. In a randomized, blinded study, animals received either intramuscular ketorolac (0.5 mg/kg or 1.0 mg/kg) and subcutaneous saline solution, subcutaneous LMWH (100 U/kg) and intramuscular saline solution, ketorolac (0.5 mg/kg or 1.0 mg/kg) and subcutaneous LMWH (100 U/kg), or intramuscular and subcutaneous saline solution given 30 minutes before ear incision and measurement of blood loss. Collagen-induced platelet aggregation was examined and anti-Xa levels were determined by using a chromogenic substrate method. As compared with results in saline-treated controls, blood loss was significantly increased in animals receiving ketorolac in a dose of 1.0 mg/kg but not in those treated with 0.5 mg/kg. The addition of LMWH did not further increase blood loss above that observed with either dose of ketorolac alone. Platelet aggregation was inhibited by both doses of ketorolac. The anti-Xa levels in the LMWH-treated animals were comparable to those measured in patients receiving these agents for prophylaxis (0.09 to 0.13 U/ml). We conclude that in the rabbit model, LMWH does not augment ketorolac-associated bleeding when both agents are used in doses comparable to those given to human patients.
 
Jet,

Even though I am a premed, I feel qualified to post another reference I found using pubmed. I am still B+ blood type. 😉

D712

Blood Coagul Fibrinolysis. 1999 Sep;10(6):367-73.
Effect of ketorolac and low-molecular-weight heparin individually and in combination on haemostasis.
Greer IA, Gibson JL, Young A, Johnstone J, Walker ID.
Source
Department of Obstetrics & Gynaecology, University of Glasgow, Glasgow Royal Infirmary, Scotland, UK. [email protected]

Abstract
Low-molecular-weight heparins, when used in surgical patients for thromboprophylaxis, may be used concurrently with ketorolac, a non-steroidal anti-inflammatory drug that is used for analgesia. Because these two agents can influence the haemostatic system, it is important to identify any such effect. The haemostatic interaction between dalteparin and ketorolac was assessed in a double-blind, placebo-controlled, randomized, crossover study of healthy male volunteers each given all four combinations of ketorolac/placebo and dalteparin/placebo. The effect of ketorolac and dalteparin on haemostasis was assessed by measuring in-vitro platelet aggregation, anti-factor-Xa, activated partial thromboplastin times and skin bleeding time. The results were analysed for evidence of an interaction between ketorolac and dalteparin. Ketorolac inhibited platelet aggregation in whole blood and platelet-rich plasma. The administration of dalteparin led to a significant increase in levels of anti-factor-Xa and a significant prolongation in the activated partial thromboplastin time, although it remained within the range of the normal population. There was no evidence of any interaction between ketorolac and dalteparin with regard to platelet aggregation, anti-factor-Xa activity or activated partial thromboplastin time. The administration of ketorolac significantly prolonged the skin bleeding time. There was a significant interaction between ketorolac and dalteparin to prolong the bleeding time, although dalteparin alone had no effect on bleeding time. There was an interaction between ketorolac and dalteparin, which affected bleeding times. Such an interaction raises the possibility of haemorrhagic complications developing perioperatively when these agents are used concomitantly. Further studies are required to examine the clinical importance of this interaction.
 
passthesashimi said:
we just got iv tylenol (ofirmev) in our OR formulary recently, and i love this stuff. anyone in private practice land using this?
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Yes, we have it. But the need is rare. I can give somebody po tylenol before they go back. I can usually give them po tylenol in PACU if needed. I could always do a tylenol suppository, but that seems kinda mean.


I have ordered ofirmev, but rarely.
 
urge said:
Why not just give it po/pr?
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We had the guy who developed the stuff and pushed it throught the FDA come give us a talk. It was fascinating - and who would a thunk it - a talk on tylenol interesting.

Anyway this is one thing i remember.

1/3 of people will NOT reach therapeutic level on an oral dose of 1gm. PR is even worse. PR dosing is horrible - i think it was like 2/3rds never reach a level that help anything.
 
pgg said:
Yes, been using it a lot since they put it in the OR omnicells, typically hang it right after the abx before incision.
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Have used it once. Kept the narcotic requirement of a patient with history of heroin abuse down to a somewhat humane level (ate through 300mcg of fentanyl in about 30 minutes after she was intubated,) for an ankle fixation. Sold me on it. Just let the team know they have to tell the patient to keep the pain pills or tylenol down to a minimum (considering the new rec to keep APAP down to 3g/day.)

As a general rule, most adults don't like things PR if they can avoid it, and may refuse. After this last run of high BMI patients (40-70 BMI) I shudder to think of trying to find the rectum when they are asleep to place a suppository. As for PO, I think it would be OK, but there is that one patient that wouldn't tolerate anything by mouth, or is so sold on narcotics (i.e. seekers,) that one would have to slip this by them in IV form. ("Yeah, its a new form of IV pain med. Works really great.")
 
We just got it. It's restricted to outpatients. Right now we're only using it for tonsils. $10 a pop, they tell me. Does anyone know why Ofirmev comes in a 1gm/100cc bottle instead of our usual 1-2cc vials?
 
epidural man said:
We had the guy who developed the stuff and pushed it throught the FDA come give us a talk. It was fascinating - and who would a thunk it - a talk on tylenol interesting.

Anyway this is one thing i remember.

1/3 of people will NOT reach therapeutic level on an oral dose of 1gm. PR is even worse. PR dosing is horrible - i think it was like 2/3rds never reach a level that help anything.
Click to expand...


Unfortunately there is not nearly such data on a change in postop analgesia when comparing 1 IV dose to 1 PO dose. The analgesia just isn't any better and it is a lot more expensive if you use it routinely.
 
:laugh::laugh:

I'm going to bed.... FAST!!!

Somethingologist: welcome I am here to learn! Cheers to that!
The blood type was a joke from another thread.

Night
D712
 
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Somethinologist said:
It's okay that you are pre-med, everyone is here to learn! I don't get the blood type part though?
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You'll get it.

Stay tuned.

I'm gonna voice an opinion soon about an

occurrence involving D712

I'm not happy with.

But now I'm hijacking my own thread. Sorry...back to

TORADOL AND LOVENOX

please
 
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Mman said:
Unfortunately there is not nearly such data on a change in postop analgesia when comparing 1 IV dose to 1 PO dose. The analgesia just isn't any better and it is a lot more expensive if you use it routinely.
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Uh....

no data true. But that doesn't mean you an claim that it isn't any better. That would mean that there IS data showing similar efficacy.

But I may be missing a study comparing the two. Does it exist?
 
pgg said:
There's no hope of getting the preop nurses on board with giving anything PO with a sip of water 2 hrs prior to start time.
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We give Entereg PO in the preop area all the time. I agree, though, that it's hard to get the nurses to follow your orders. Unless they have some sort of inservice on the topic, they'll just hang the old "it's against our protocol" flag.

jetproppilot said:
Anyone aware of any studies for or against Toradol useage when Lovenox is on board?

Thanks in advance.
Click to expand...

In my experience, orthopods are very gunshy about anticoagulants, which is ironic since the DVT rate in their patient population is so high. As a matter of fact, when the Chest guidelines said ASA was inadequate for DVT prophylaxis (which it is), the Ortho guys just developed their own guidelines. Most of the time they make anticoagulant decisions based more on anecdotal evidence than anything else.

As for Toradol and Lovenox, we give them together routinely in surgery. If a patient is s/p colectomy, and on a fast-track protocol, he/she will most likely be getting both around the clock...assuming the age and kidney function are permissable.
 
IV Tylenol costs $10. When my hospital is billing 75-110k for a post. spinal fusion.... Well.... it's just not that big of a deal in the grand scheme of things.

Bioavailability is 100%. That is something I can live with.
 
sevoflurane said:
IV Tylenol costs $10. When my hospital is billing 75-110k for a post. spinal fusion.... Well.... it's just not that big of a deal in the grand scheme of things.

Bioavailability is 100%. That is something I can live with.
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Thanks for all the replies about Toradol/Lovenox. I'm very appreciative.

We spoke to the IV Tylenol Dude...the thing that turned me off was the setup...it's not in a 3mL syringe, it's in a

100mL bottle.

Another thing to hook into the IV. Headaches of where to put the things...seems just a few bottles would occupy a whole Pyxis drawer...etc etc

Do you think it's worth the trouble? Why not just give ketorolac? And if you can't give ketorolac give 1g PO Tylenol in day surgery?
 
jetproppilot said:
Another thing to hook into the IV. Headaches of where to put the things...
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Unplug antibiotics, plug in Tylenol. Same tubing, let it drip while they prep/start. It probably takes less time than getting a syringe & needle, drawing up 1 mL of drug, and injecting it.

jetproppilot said:
seems just a few bottles would occupy a whole Pyxis drawer...etc etc
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They do, and this is kind of a PITA. But our pharmacy refills the Omnicells during the day. I've yet to face an empty bin.

jetproppilot said:
Do you think it's worth the trouble? Why not just give ketorolac? And if you can't give ketorolac give 1g PO Tylenol in day surgery?
Click to expand...

So far, I think it's worth the trouble (which isn't much). I decided to use it on everybody for a couple weeks to see if I could perceive a difference. And they seem to do well with less narcotic, which everybody likes.

I also give ketorolac whenever I can, which is sometimes limited by ortho's objections.

PO Tylenol in preop two hours prior is 73x the hassle as the 100 mL IV bottle.
 
jetproppilot said:
Had a conversation today with an ortho buddy who believes toradol is contraindicated when Lovenox is being used.

For the premeds/early med students, Lovenox (enoxaparin) is a low molecular weight heparin commononly used postoperatively for DVT prophylaxis.

Anyone aware of any studies for or against Toradol useage when Lovenox is on board?

Thanks in advance.
Click to expand...

Spoke to ortho buddy about the fact that Toradol +Lovenox= OK

Reply:

"Whatever you want, dude."

What a great gig I have.

Working with surgeons that are amenable to changing their thinking.
 
jetproppilot said:
Spoke to ortho buddy about the fact that Toradol +Lovenox= OK

Reply:

"Whatever you want, dude."

What a great gig I have.

Working with surgeons that are amenable to changing their thinking.
Click to expand...

👍

We often make fun of those ortho folks - like they are apes that just want to drill.

How quickly we forget that most of them were the guys getting 98% on all the med school tests and scoring 260+ on USMLE.
 
epidural man said:
👍

We often make fun of those ortho folks - like they are apes that just want to drill.

How quickly we forget that most of them were the guys getting 98% on all the med school tests and scoring 260+ on USMLE.
Click to expand...

Yeah dude... I can't take credit for this, but it has been said here on sdn:

Ortho:

Turning the Smartest Medical Students into the Dumbest Physicians.

They have a broken bone... we need to fix it. 😀

Of course this is a slight exageration.
 
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