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Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial.
Ann Emerg Med 2017; 70(2):177-184AE

Abstract

STUDY OBJECTIVE

Nonsteroidal anti-inflammatory drugs are used extensively for the management of acute and chronic pain, with ketorolac tromethamine being one of the most frequently used parenteral analgesics in the emergency department (ED). The drugs may commonly be used at doses above their analgesic ceiling, offering no incremental analgesic advantage while potentially adding risk of harm. We evaluate the analgesic efficacy of 3 doses of intravenous ketorolac in ED patients with acute pain.

METHODS

We conducted a randomized, double-blind trial to assess the analgesic efficacy of 3 doses of intravenous ketorolac (10, 15, and 30 mg) in patients aged 18 to 65 years and presenting to the ED with moderate to severe acute pain, defined by a numeric rating scale score greater than or equal to 5. We excluded patients with peptic ulcer disease, gastrointestinal hemorrhage, renal or hepatic insufficiency, allergies to nonsteroidal anti-inflammatory drugs, pregnancy or breastfeeding, systolic blood pressure less than 90 or greater than 180 mm Hg, and pulse rate less than 50 or greater than 150 beats/min. Primary outcome was pain reduction at 30 minutes. We recorded pain scores at baseline and up to 120 minutes. Intravenous morphine 0.1 mg/kg was administered as a rescue analgesic if subjects still desired additional pain medication at 30 minutes after the study drug was administered. Data analyses included mixed-model regression and ANOVA.

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.

Authors+Show Affiliations

Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY. Electronic address: smotov@maimonidesmed.org.Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY.Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY.Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY.Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY.Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY.Department of Pharmacy, New York City Health + Hospitals, Brooklyn, NY.Department of Pharmacy, Maimonides Medical Center, Brooklyn, NY.Department of Pharmacy, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY.Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY.Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY.Office of Research Administration, Maimonides Medical Center, Brooklyn, NY; Department of Medicine, Albert Einstein College of Medicine, Bronx, NY.Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY.

Pub Type(s)

Comparative Study
Journal Article
Randomized Controlled Trial

Language

eng

PubMed ID

27993418

Citation

Motov, Sergey, et al. "Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: a Randomized Controlled Trial." Annals of Emergency Medicine, vol. 70, no. 2, 2017, pp. 177-184.
Motov S, Yasavolian M, Likourezos A, et al. Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med. 2017;70(2):177-184.
Motov, S., Yasavolian, M., Likourezos, A., Pushkar, I., Hossain, R., Drapkin, J., ... Fromm, C. (2017). Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial. Annals of Emergency Medicine, 70(2), pp. 177-184. doi:10.1016/j.annemergmed.2016.10.014.
Motov S, et al. Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: a Randomized Controlled Trial. Ann Emerg Med. 2017;70(2):177-184. PubMed PMID: 27993418.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial. AU - Motov,Sergey, AU - Yasavolian,Matthew, AU - Likourezos,Antonios, AU - Pushkar,Illya, AU - Hossain,Rukhsana, AU - Drapkin,Jefferson, AU - Cohen,Victor, AU - Filk,Nicholas, AU - Smith,Andrew, AU - Huang,Felix, AU - Rockoff,Bradley, AU - Homel,Peter, AU - Fromm,Christian, Y1 - 2016/12/16/ PY - 2016/05/19/received PY - 2016/09/29/revised PY - 2016/10/12/accepted PY - 2016/12/21/pubmed PY - 2017/10/19/medline PY - 2016/12/21/entrez SP - 177 EP - 184 JF - Annals of emergency medicine JO - Ann Emerg Med VL - 70 IS - 2 N2 - STUDY OBJECTIVE: Nonsteroidal anti-inflammatory drugs are used extensively for the management of acute and chronic pain, with ketorolac tromethamine being one of the most frequently used parenteral analgesics in the emergency department (ED). The drugs may commonly be used at doses above their analgesic ceiling, offering no incremental analgesic advantage while potentially adding risk of harm. We evaluate the analgesic efficacy of 3 doses of intravenous ketorolac in ED patients with acute pain. METHODS: We conducted a randomized, double-blind trial to assess the analgesic efficacy of 3 doses of intravenous ketorolac (10, 15, and 30 mg) in patients aged 18 to 65 years and presenting to the ED with moderate to severe acute pain, defined by a numeric rating scale score greater than or equal to 5. We excluded patients with peptic ulcer disease, gastrointestinal hemorrhage, renal or hepatic insufficiency, allergies to nonsteroidal anti-inflammatory drugs, pregnancy or breastfeeding, systolic blood pressure less than 90 or greater than 180 mm Hg, and pulse rate less than 50 or greater than 150 beats/min. Primary outcome was pain reduction at 30 minutes. We recorded pain scores at baseline and up to 120 minutes. Intravenous morphine 0.1 mg/kg was administered as a rescue analgesic if subjects still desired additional pain medication at 30 minutes after the study drug was administered. Data analyses included mixed-model regression and ANOVA. 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. SN - 1097-6760 UR - https://www.unboundmedicine.com/medline/citation/27993418/Comparison_of_Intravenous_Ketorolac_at_Three_Single_Dose_Regimens_for_Treating_Acute_Pain_in_the_Emergency_Department:_A_Randomized_Controlled_Trial_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0196-0644(16)31244-6 DB - PRIME DP - Unbound Medicine ER -