Ketorolac

# Ketorolac ## Overview - **Classification**: Nonsteroidal Anti-inflammatory Drug (NSAID), specifically a potent analgesic. - **Mechanism**: Inhibits prostaglandin synthesis by non-selectively blocking cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2) enzymes. ## Primary Indications 1. **Moderate to Severe Acute Pain** - Short-term management (max 5 days). 2. **Postoperative Pain** - Reduction of opioid requirements. 3. **Ophthalmic**: Seasonal allergic conjunctivitis, post-operative ocular inflammation. ## Adult Dosing ### Standard Dosing **Moderate to Severe Acute Pain (IV/IM)** - **Dose**: - Initial: **30 mg IV/IM** once. - Maintenance: **15-30 mg IV/IM q6h PRN**. - For patients <50 kg, ≥65 years, or with impaired renal function: Initial **15 mg IV/IM** once, then **15 mg IV/IM q6h PRN**. - **Frequency**: Every 6 hours PRN - **Route**: Intravenous (IV) or Intramuscular (IM) - **Duration**: Maximum **5 days** (combined IV/IM and oral therapy). **Moderate to Severe Acute Pain (Oral)** - **Dose**: **10 mg PO** - **Frequency**: Every 4-6 hours PRN - **Route**: Oral (PO) - **Duration**: Should only be used as continuation after IV/IM. Total combined duration (IV/IM + PO) **≤ 5 days**. Max daily **40 mg PO**. **Ophthalmic** - **Dose**: **1 drop** - **Frequency**: To affected eye **QID** - **Route**: Ocular - **Duration**: Up to 4 weeks (allergic conjunctivitis), up to 2 weeks (post-op inflammation). **Nasal Spray** - **Dose**: **31.5 mg** (one spray in each nostril) - **Frequency**: Every 6-8 hours PRN - **Route**: Intranasal - **Duration**: Maximum **5 days**. Max daily **126 mg** (4 sprays/day). ### Dose Adjustments - **Renal Impairment**: - **CrCl <30 mL/min**: **Contraindicated**. - **CrCl 30-60 mL/min**: Reduce IV/IM dose to **15 mg q6h**. Max daily **60 mg**. - **Hepatic Impairment**: No specific dose adjustment, but use with **caution** due to risk of increased liver enzymes. - **Elderly Patients (≥65 years)**: Use lower adult doses (e.g., **15 mg IV/IM q6h**). Max daily **60 mg**. ## Pediatric Dosing ### Neonates (0-28 days) - **Dose**: **Contraindicated**. - **Special Notes**: Risk of severe renal impairment, bleeding, and necrotizing enterocolitis. ### Infants (1-12 months) - **Dose**: **Contraindicated**. - **Special Notes**: Insufficient data and increased risk of adverse effects, especially renal. ### Children (1-12 years) - **Indication**: Limited to single-dose use for moderate-to-severe postoperative pain. - **Dose**: **0.5 mg/kg IV/IM** - **Frequency**: **Single dose** is preferred. If repeated, **q6h for max 48 hours**. - **Maximum**: **15 mg/dose** (for body weight <50 kg), **30 mg/dose** (for body weight ≥50 kg). Max daily **60 mg**. - **Special Notes**: Use with extreme caution. Ensure adequate hydration. Not for routine use. ### Adolescents (13-18 years) - **Dose**: Use lower end of adult dosing, e.g., **15 mg IV/IM q6h**. - **Maximum**: Max daily **60 mg IV/IM**. - **Special Notes**: Total treatment duration **≤ 5 days**. Transition to oral therapy if appropriate. ## Safety Information ### Contraindications - **Absolute**: Active peptic ulcer disease, recent GI bleeding/perforation. - **Absolute**: Advanced renal impairment (CrCl <30 mL/min). - **Absolute**: History of asthma, urticaria, or allergic-type reactions to NSAIDs/aspirin. - **Absolute**: Peri-operative pain in the setting of Coronary Artery Bypass Graft (CABG) surgery. - **Absolute**: Labor and delivery, pregnancy (third trimester). - **Absolute**: Concomitant NSAID or aspirin use, bleeding diathesis, cerebrovascular bleeding. - **Absolute**: Hypovolemia or dehydration. ### Common Adverse Effects - **Very Common (>10%)**: Headache, nausea, dyspepsia, abdominal pain. - **Common (1-10%)**: Dizziness, somnolence, diarrhea, vomiting, flatulence, edema. - **Serious but Rare**: GI ulceration/bleeding/perforation, acute renal failure, anaphylaxis, severe hypertension, thrombotic events (MI, stroke). ### Key Drug Interactions - **Anticoagulants (e.g., Warfarin, Heparin)**: Increased risk of bleeding. **Avoid concomitant use.** - **Lithium**: Increased lithium plasma levels and toxicity. **Monitor lithium levels closely.** - **Methotrexate**: Increased methotrexate levels and toxicity. **Use with caution; consider dose reduction of methotrexate.** - **Diuretics (e.g., Furosemide, Thiazides)**: Reduced diuretic and antihypertensive effects; increased risk of renal impairment. **Monitor renal function.** - **ACE Inhibitors/ARBs**: Reduced antihypertensive effect; increased risk of renal impairment. **Monitor blood pressure and renal function.** - **SSRIs/SNRIs**: Increased risk of GI bleeding. **Use with caution.** ## Monitoring & Follow-up - **Before Treatment**: Baseline renal function (SCr, CrCl), hepatic function (ALT/AST), complete blood count (CBC). - **During Treatment**: - Renal function: Monitor SCr and urine output, especially in high-risk patients. - GI bleeding: Observe for signs (melena, hematemesis). - Blood pressure: Monitor regularly, especially in hypertensive patients. - Fluid retention: Monitor for edema. - **Clinical Signs**: Watch for signs of GI bleeding, changes in urine output, unexplained rash, or allergic reactions. ## Clinical Pearls - 💡 **Duration Limit**: Strictly adhere to the **5-day maximum duration** for IV/IM/oral ketorolac to minimize GI and renal adverse effects. - 💡 **Bridge Therapy**: Ketorolac is often used to bridge patients from parenteral to oral analgesia. - 💡 **Hydration**: Ensure patients are well-hydrated before administration, especially for IV/IM use, to mitigate renal risks. - 💡 **Not for Chronic Pain**: Ketorolac is not indicated for chronic pain management. - 💡 **Opioid-Sparing**: Can be effective in reducing opioid requirements in acute pain settings. > **⚠️ Important**: This information is for educational purposes only. Always consult current prescribing information, local guidelines, and clinical judgment before prescribing.