No

Nonsteroidal Anti-Inflammatory Agent (NSAID)

Dental: Short-term (<5 days) management of pain

Medical: Short-term (<5 days) management of pain; first parenteral NSAID for analgesia; 30 mg provides the analgesia comparable to 12 mg of morphine or 100 mg of meperidine

B/D (3rd trimester)

In patients who have developed nasal polyps, angioedema, or bronchospastic reactions to other NSAIDs, active peptic ulcer disease, recent GI bleeding or perforation, patients with advanced renal disease or risk of renal failure, labor and delivery, nursing mothers, patients with hypersensitivity to ketorolac, aspirin, or other NSAIDs, prophylaxis before major surgery, suspected or confirmed cerebrovascular bleeding, hemorrhagic diathesis, concurrent ASA or other NSAIDs, epidural or intrathecal administration, concomitant probenecid

Use extra caution and reduce dosages in the elderly because it is cleared renally somewhat slower, and the elderly are also more sensitive to the renal effects of NSAIDs; use with caution in patients with congestive heart failure, hypertension, decreased renal or hepatic function, history of GI disease (bleeding or ulcers), or those receiving anticoagulants

Percentage unknown: Renal impairment, wound bleeding (with I.M.), postoperative hematomas

1% to 10%:

Cardiovascular: Edema

Central nervous system: Drowsiness, dizziness, headache, pain

Gastrointestinal: Nausea, dyspepsia, diarrhea, gastric ulcers, indigestion

Local: Pain at injection site

Miscellaneous: Diaphoresis (increased)

<1%: Mental depression, purpura, aphthous stomatitis, rectal bleeding, peptic ulceration, change in vision, oliguria, dyspnea

Symptoms of overdose include diarrhea, pallor, vomiting, labored breathing, apnea, metabolic acidosis, leukocytosis, renal failure

Management of a nonsteroidal anti-inflammatory drug (NSAID) intoxication is primarily supportive and symptomatic. Fluid therapy is commonly effective in managing the hypotension that may occur following an acute NSAID overdose, except when this is due to an acute blood loss. Seizures tend to be very short-lived and often do not require drug treatment; although, recurrent seizures should be treated with I.V. diazepam. Since many of the NSAIDs undergo enterohepatic cycling, multiple doses of charcoal may be needed to reduce the potential for delayed toxicities; NSAIDs are highly bound to plasma proteins; therefore, hemodialysis and peritoneal dialysis are not useful.

Decreased effect of diuretics

Increased toxicity: Lithium, methotrexate increased drug level; increased effect/toxicity with salicylates, probenecid, anticoagulants

Ketorolac tromethamine injection should be stored at controlled room temperature and protected from light; injection is clear and has a slight yellow color; precipitation may occur at relatively low pH values

Compatible with NS, D₅W, D₅NS, LR

Incompatible with meperidine, morphine, promethazine, and hydroxyzine

Inhibits prostaglandin synthesis by decreasing the activity of the enzyme, cyclo-oxygenase, which results in decreased formation of prostaglandin precursors

Analgesic effect:

Onset of action: I.M.: Within 10 minutes

Peak effect: Within 75-150 minutes

Duration of action: 6-8 hours

Absorption: Oral: Well absorbed

Time to peak serum concentration: I.M.: 30-60 minutes

Distribution: Crosses placenta; crosses into breast milk; poor penetration into CSF

Protein binding: 99%

Metabolism: In the liver

Half-life: 2-8 hours; increased 30% to 50% in elderly

Elimination: Renal excretion, 61% appearing in the urine as unchanged drug

Note: The use of ketorolac in children <16 years of age is outside of product labeling

Single-dose treatment:

I.M., I.V.: 0.4-1 mg/kg as a single dose; Note: Limited information exists. Single I.V. doses of 0.5 mg/kg, 0.75 mg/kg, 0.9 mg/kg and 1 mg/kg have been studied in children 2-16 years of age for postoperative analgesia. One study (Maunuksela, 1992) used a titrating dose starting with 0.2 mg/kg up to a total of 0.5 mg/kg (median dose required: 0.4 mg/kg).

Oral: One study used 1 mg/kg as a single dose for analgesia in 30 children (mean ± SD age: 3 ± 2.5 years) undergoing bilateral myringotomy

Multiple-dose treatment: I.M., I.V., Oral: No pediatric studies exist; one report (Buck, 1994) of the clinical experience with ketorolac in 112 children, 6 months to 19 years of age (mean: 9 years), described usual I.V. maintenance doses of 0.5 mg/kg every 6 hours (mean dose: 0.52 mg/kg; range: 0.17-1 mg/kg)

Adults (pain relief usually begins within 10 minutes with parenteral forms):

Oral: 10 mg every 4-6 hours as needed for a maximum of 40 mg/day; on day of transition from I.M. to oral: maximum oral dose: 40 mg (or 120 mg combined oral and I.M.); maximum 5 days administration

I.M.: Initial: 30-60 mg, then 15-30 mg every 6 hours as needed for up to 5 days maximum; maximum dose in the first 24 hours: 150 mg with 120 mg/24 hours for up to 5 days total

I.V.: Initial: 30 mg, then 15-30 mg every 6 hours as needed for up to 5 days maximum; maximum daily dose: 120 mg for up to 5 days total

Ophthalmic: Instill 1 drop in eye(s) 4 times/day for up to 7 days

Elderly >65 years: Renal insufficiency or weight <50 kg:

I.M.: 30 mg, then 15 mg every 6 hours

I.V.: 15 mg every 6 hours as needed for up to 5 days total; maximum daily dose: 60 mg

Potassium: Hyperkalemia has been reported. The elderly and those with renal insufficiency are at greatest risk. Monitor potassium serum concentration in those at greatest risk. Avoid salt substitutes.

Sodium: Hyponatremia from sodium retention. Suspect secondary to suppression of renal prostaglandin. Monitor serum concentration and fluid status. May need to restrict fluid.

Monitor response (pain, range of motion, grip strength, mobility, ADL function), inflammation; observe for weight gain, edema; monitor renal function (serum creatinine, BUN, urine output); observe for bleeding, bruising; evaluate gastrointestinal effects (abdominal pain, bleeding, dyspepsia); mental confusion, disorientation, CBC, liver function tests

Serum concentration: Therapeutic: 0.3-5 mg/mL; Toxic: >5 mg/mL

chloride (S), sodium (S), bleeding time

May cause drowsiness or dizziness; may rarely produce depression

May decrease lithium clearance resulting in an increase in serum lithium levels and potential lithium toxicity; monitor serum lithium levels

No information available to require special precautions

NSAID formulations are known to reversibly decrease platelet aggregation via mechanisms different than observed with aspirin. The dentist should be aware of the potential of abnormal coagulation. Caution should also be exercised in the use of NSAIDs in patients already on anticoagulant therapy with drugs such as warfarin (Coumadin®).

If self-administered, use exactly as directed (do not increase dose or frequency); adverse reactions can occur with overuse. Do not take longer than 5 days without consulting medical advisor. Take with food or milk. While using this medication, do not use alcohol, other prescription or OTC medications including aspirin, aspirin-containing medications, or other NSAIDs without consulting prescriber. Maintain adequate hydration (2-3 L/day of fluids unless instructed to restrict fluid intake). You may experience nausea, vomiting, gastric discomfort (frequent mouth care, small frequent meals, chewing gum, or sucking lozenges may help). GI bleeding, ulceration, or perforation can occur with or without pain. Stop taking medication and report ringing in ears; persistent cramping or pain in stomach; unresolved nausea or vomiting; difficulty breathing or shortness of breath; unusual bruising or bleeding (mouth, urine, stool); skin rash; unusual swelling of extremities; chest pain; or palpitations. Pregnancy/breast-feeding precautions: Inform prescriber if you are or intend to be pregnant. Do not breast-feed.

Monitor for signs of pain relief, such as an increased appetite and activity

Injection: 15 mg/mL (1 mL); 30 mg/mL (1 mL, 2 mL)

Solution, ophthalmic: 0.5% (5 mL)

Tablet: 10 mg

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