Comparing two doses of intramuscular ketorolac for treatment of acute musculoskeletal pain in a military emergency department

What is the analgesic ceiling dose of ketorolac for treating acute pain in the ED?

“…The American Academy of Emergency Medicine recommends NSAID administration at the lowest effective dose to reduce the risk of renal insufficiency, heart failure, and GI bleeding 15. Patients in an emergency setting likely can achieve sufficient pain control with a 10- to 15-mg parenteral dose of ketorolac 11-13. However, this low-dose strategy may not account for the potential of a longer duration of action based on ketorolac's linear elimination, which could be desirable outside of the ED 16…”

“…10 Although historical prescribing practices may dictate ordering preferences, several recent, well-designed clinical trials have challenged tradition and suggest an effective analgesic ceiling dose between 10 mg and 15 mg in the ED. [11][12][13] Eidinejad and colleagues conducted a randomized, doubleblind, noninferiority trial of IV ketorolac in adults presenting to the ED with renal colic. 11 The investigators randomized 165 patients with renal colic into three equal groups.…”

“…This dosing may be related to clinician consensus that the medication may be physiologically available for longer durations; however, no published studies support this claim about the drug's duration of action 10. Although historical prescribing practices may dictate ordering preferences, several recent, well-designed clinical trials have challenged tradition and suggest an effective analgesic ceiling dose between 10 mg and 15 mg in the ED 11-13…”

“…Last, a single-blinded, randomized trial of 110 adults presenting to a military ED compared the efficacy of a 15-mg IM ketorolac dose to a 60-mg dose to determine a change in pain from baseline 13. The researchers concluded that 15 mg of IM ketorolac was noninferior to 60 mg for treating acute musculoskeletal pain in an ED 13…”

Superior analgesic efficacy of preemptive low-dose ketorolac compared with parecoxib after total knee arthroplasty: A retrospective propensity score matching study

“…This drug has shown efficacy in providing analgesia; however, evidence suggests a ceiling effect for its potency. 7,8 In addition, ketorolac is associated with adverse gastrointestinal, renal, and cardiovascular events, some of which may be dose-dependent or duration-dependent. 5 Studies on low-dose ketorolac have demonstrated effective analgesia after spinal fusion surgery compared with a placebo.…”