We’ve all been there. You’re on green team (fast-track), another complaint of back or tooth pain that never really trialed oral meds but definitely wants something more. Here comes IM ketorolac to save the day.
Here, we aim to cover some quick pearls on the Do’s and the Don’t’s of ketorolac to further inform the use of the medication.
How much ketorolac should I give?
The analgesic ceiling of IV ketorolac is something we frequently discuss in the ED, but less regularly have I heard discussed whether that same analgesic ceiling applies to IM ketorolac. To review, a 2017 randomized-controlled trial published in Annals found no statistically significant difference in pain scores or rate of rescue analgesia in 240 patients randomized to receive 10 mg, 15 mg, or 30 mg of IV ketorolac (1). This study suggests the analgesic ceiling of ketorolac is around 10 mg (although we commonly give 15 mg because big pharma puts ketorolac in 15 mg vials). For IM ketorolac, studies have found no benefit to administering greater than 15 mg, such as in this 2021 paper published in the American Journal of Emergency Medicine (2).
Answer: There is no benefit to providing greater than 10 mg ketorolac (although 15 mg is easier for our nurses) in both the IV and IM routes.
Will my patient feel better if I give them ketorolac compared to other medications?
Data thus far, including a 1998 paper published in Academic Emergency Medicine, have failed to find a benefit to IM ketorolac over PO ibuprofen (3). In the abovementioned study, patients received either IM ketorolac with a PO placebo capsule or PO ibuprofen and an IM placebo solution. Therefore this well-conducted double-blind RCT suggests a limited benefit to IM ketorolac over PO ibuprofen. This topic is discussed further in a review article by Sanjay Aurora from EM RAP, who questions the use of IV and IM ketorolac, except in the cases of patients with an inability to tolerate PO (4). Limited data currently exists comparing IV ketorolac to PO ibuprofen. Examples of the equivocal nature of the current studies are an RCT which found no difference in ibuprofen vs ketorolac for postoperative urogynecologic pain (5). In contrast, another study found IV ketorolac and morphine to have similar efficacy (6).
Answer: The effect of the IM ketorolac on your patient is likely the same as PO ibuprofen, although the placebo component may differ.
Does using ketorolac harm my patients?
The monetary cost of ketorolac has decreased, with a single unit costing approximately $0.55 compared to $0.03 for ibuprofen (5). Therefore, there doesn’t seem to be much of a financial burden on patients nowadays. From a complication standpoint, ketorolac does have the highest risk of GI complications, with ibuprofen having a RR of upper GI bleed of 4.6 compared to ketorolac at 14.54 (7).
Answer: Although ketorolac doesn’t harm patients much monetarily, liberal use of the medication does increase the risk of one of your patients developing a GI bleed.
Authored by Jose Reyes, MD
References:
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): p. 177-184.
Turner, N.J., et al., Comparing two doses of intramuscular ketorolac for treatment of acute musculoskeletal pain in a military emergency department. Am J Emerg Med, 2021. 50: p. 142-147.
Neighbor, M.L. and K.A. Puntillo, Intramuscular ketorolac vs oral ibuprofen in emergency department patients with acute pain. Acad Emerg Med, 1998. 5(2): p. 118-22.
Arora, S., J.G. Wagner, and M. Herbert, Myth: parenteral ketorolac provides more effective analgesia than oral ibuprofen. Cjem, 2007. 9(1): p. 30-2.
Dwarica, D.S., et al., Comparing Ketorolac With Ibuprofen for Postoperative Pain: A Randomized Clinical Trial. Female Pelvic Med Reconstr Surg, 2020. 26(4): p. 233-238.
Rainer, T.H., et al., Cost effectiveness analysis of intravenous ketorolac and morphine for treating pain after limb injury: double blind randomised controlled trial. Bmj, 2000. 321(7271): p. 1247-51.
Lin, M. Paucis Verbis: NSAIDs and upper GI bleeds [Internet]. ALiEM. 2011 [cited 2023 Aug 4];Available from: https://www.aliem.com/paucis-verbis-nsaids-and-upper-gi-bleeds/