Ketorol

# Ketorol ## Overview - **Classification**: Non-steroidal Anti-inflammatory Drug (NSAID) - Pyrrolo-pyrrole derivative - **Mechanism**: Inhibits prostaglandin synthesis by non-selectively blocking cyclooxygenase (COX-1 and COX-2) enzymes. Provides analgesic, anti-inflammatory, and antipyretic effects. ## Primary Indications 1. **Short-term Management of Moderately Severe Acute Pain**: Primarily for post-operative pain. 2. **Opioid-Sparing Analgesia**: Can reduce opioid requirements when used concurrently. ## Adult Dosing ### Standard Dosing **Moderately Severe Acute Pain (IV/IM)** - **Initial Dose**: **30 mg IV** or **60 mg IM** (single dose) - **Frequency**: **30 mg IV** or **30 mg IM** every **6 hours** - **Route**: Intravenous (IV), Intramuscular (IM) - **Duration**: Maximum **5 days** (combined IV/IM and oral) **Moderately Severe Acute Pain (Oral, Step-down from IV/IM)** - **Dose**: **10 mg** - **Frequency**: Every **4-6 hours** - **Route**: Oral - **Duration**: Maximum **5 days** (combined IV/IM and oral) ### Dose Adjustments - **Renal Impairment**: - **CrCl 30-60 mL/min**: Reduce dose by 50% (e.g., **15 mg IV/IM** every 6 hours, or **10 mg PO** every 4-6 hours, if appropriate). - **CrCl <30 mL/min**: **Contraindicated**. - **Hepatic Impairment**: Use with caution. No specific dose adjustments; monitor for signs of hepatic toxicity. - **Elderly Patients (≥65 years)**: - Initial dose **15 mg IV** or **30 mg IM** (single dose). - Maintenance: **15 mg IV/IM** every **6 hours**. - Maximum **5 days** duration. - Increased risk of adverse effects (GI, renal). ## Pediatric Dosing ### Neonates (0-28 days) - **Not Recommended**: **Contraindicated** due to risk of serious renal and GI adverse effects. ### Infants (1-12 months) - **Not Recommended**: **Avoid use** due to lack of established safety and efficacy, and high risk of adverse effects. ### Children (1-12 years) - **Limited Use (e.g., Post-operative Pain)**: - **Dose**: **0.5 mg/kg IV** or **IM** (single dose only) - **Frequency**: Single dose for acute pain. Repeat doses generally **not recommended**. - **Maximum**: Single dose not to exceed **15 mg**. - **Special Notes**: Use only when benefits outweigh risks. Closely monitor renal function and hydration status. ### Adolescents (13-18 years) - **Approach to Adult Dosing**: - **Dose**: **0.5 mg/kg IV** or **IM** initially. - **Frequency**: Up to **30 mg IV/IM** every **6 hours** for multiple doses. - **Maximum**: **90 mg/day IV/IM** or **40 mg/day PO**. - **Special Notes**: Still follow the **5-day maximum total duration**. Ensure adequate hydration and monitor renal function. ## Safety Information ### Contraindications - **Absolute**: Active peptic ulcer disease, recent GI bleeding/perforation. - **Absolute**: Advanced renal impairment (CrCl <30 mL/min), acute kidney injury. - **Absolute**: History of asthma, urticaria, or allergic-type reactions to NSAIDs/aspirin. - **Absolute**: Patients undergoing CABG surgery (peri-operative pain). - **Absolute**: Concurrent use with other NSAIDs, aspirin, probenecid, or pentoxifylline. - **Absolute**: Pregnancy (late trimester), labor and delivery. - **Absolute**: Prophylactic analgesia before major surgery. - **Absolute**: Cerebrovascular bleeding. - **Absolute**: Children <2 years (generally), and caution up to 12 years. ### Common Adverse Effects - **Very Common (>10%)**: Headache, GI discomfort (nausea, dyspepsia, abdominal pain). - **Common (1-10%)**: Diarrhea, dizziness, edema, hypertension. - **Serious but Rare**: Gastrointestinal bleeding/ulceration/perforation, acute renal failure, anaphylactoid reactions, serious skin reactions (SJS/TEN), hepatotoxicity, cardiovascular thrombotic events (MI, stroke). ### Key Drug Interactions - **Anticoagulants (Warfarin, Heparins)**: Increased risk of bleeding. **Avoid concurrent use**. - **Lithium/Methotrexate**: Increased levels/toxicity of Lithium/Methotrexate. **Monitor levels closely**, consider alternative. - **Diuretics (Furosemide, Thiazides)**: Reduced diuretic and antihypertensive effects; increased risk of renal impairment. **Monitor blood pressure and renal function**. - **ACE Inhibitors/ARBs**: Increased risk of renal impairment and hyperkalemia. **Monitor renal function**. - **SSRIs/SNRIs**: Increased risk of GI bleeding. **Use with caution**, monitor for signs of bleeding. - **Other NSAIDs/Aspirin**: Increased risk of GI toxicity. **Contraindicated**. - **Probenecid**: Increased ketorolac levels. **Contraindicated**. - **Pentoxifylline**: Increased risk of bleeding. **Contraindicated**. ## Monitoring & Follow-up - **Before Treatment**: Baseline renal function (SCr, CrCl), liver function tests (LFTs), complete blood count (CBC). - **During Treatment**: - **Renal Function**: Monitor SCr, urine output, especially in dehydrated or elderly patients. - **GI Bleeding**: Monitor for signs of bleeding (dark stools, coffee-ground emesis). - **Fluid Retention**: Monitor for edema, weight gain, blood pressure. - **Pain Relief**: Assess pain scores regularly. - **Clinical Signs**: Watch for allergic reactions, skin rash, severe abdominal pain, persistent nausea/vomiting, unusual bleeding/bruising. ## Clinical Pearls - 💡 **Max Duration**: Always adhere to the **5-day maximum** combined duration for all routes of administration to minimize serious adverse effects, especially GI and renal. - 💡 **Hydration**: Ensure patients are adequately hydrated, especially when administering IV/IM, to minimize risk of acute kidney injury. - 💡 **Step-down**: Consider switching to oral ketorolac (10 mg every 4-6 hours) or other oral analgesics as soon as feasible after IV/IM administration. - 💡 **Not for Chronic Pain**: Ketorolac is for acute, moderately severe pain only; it is **not indicated for chronic use**. - 💡 **Elderly/Renal Patients**: Doses must be reduced in elderly or renally impaired patients due to increased risk of adverse effects. > **⚠️ Important**: This information is for educational purposes only. Always consult current prescribing information, local guidelines, and clinical judgment before prescribing.