Does increasing the dose of intravenous ketorolac improve analgesia in emergency department patients with a wide variety of pain syndromes?
Title of Paper:
Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomised Controlled Trial
Journal and Year:
Annals of Emergency Medicine 2016
Adults <65 years old presenting to ED with acute flank, abdominal, musculoskeletal or headache pain ≥ 5/10 on pain scale
Ketorolac IV dosed at 10, 15 or 30mg
No control group. Comparison is between the three treatment doses.
Reduction in pain score at 30minutes post treatment.
Summary of Results:
All three doses showed significant pain reduction, with no difference in reduction of pain score between the three groups and no difference in use of rescue analgesia (morphine) between the groups.
There was no difference in immediately apparent side-effects (dizziness, nausea, headache) between the groups.
Sample size calculated and achieved for all groups
Primary outcome measures relevant to Emergency Department practice
No placebo group for comparison
Short follow up (to 120 minutes) raises question if higher dose could have prolonged analgesic benefit
At this length of follow up the side effects recorded are only those that would be immediately apparent, and not the most relevant concerns with ketorolac use. GI bleeding and Acute Kidney Injury would require longer follow up.
Clinical Bottom Line:
As has been described with other NSAIDs, ketorolac likely has an analgesic ceiling, and it’s lower than we think. While they can’t assess the longer time side effects, it would be a safe estimate to say they’d be less likely the lower the dose you use – so my initial go to dose for IV ketorolac is likely to be 10mg in future, though I don’t know what impact this would have on the IM dosing.