Ketorolac for sickle cell vaso-occlusive crisis pain in the emergency department: lack of a narcotic-sparing effect

Wright, Seth W.; Norris, Robert L.; Mitchell, T. R. B.

doi:10.1016/s0196-0644(05)82929-4

Cited by 50 publications

(21 citation statements)

References 17 publications

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“…Only 4 randomized studies [29][30][31][32] on NSAIDs have been conducted on VOC, and the results of those trials were contradictory, with the evidence level of NSAID efficacy also low. The authors of 2 adult and 1 pediatric controlled study compared parenteral ketorolac to placebo 29,31,32 and another diflunisal versus placebo.…”

Section: Discussionmentioning

confidence: 99%

“…The authors of 2 adult and 1 pediatric controlled study compared parenteral ketorolac to placebo 29,31,32 and another diflunisal versus placebo. 30 Two of those studies 29,32 concerned single-dose administrations with short follow-up periods (4 and 6 hours, respectively), and no significant differences were found for the average opioid requirement or pain relief. In contrast, Perlin et al 31 evaluated 21 hospitalized adults and found a significant one-third reduction of the meperidine dose and a shorter duration of hospitalization for the ketorolac group.…”

Section: Discussionmentioning

confidence: 99%

“…[29][30][31][32] Those studies included small numbers of patients and obtained conflicting results. Moreover, the use of NSAIDs in patients with SCD raises other concerns.…”

Section: Introductionmentioning

confidence: 99%

“…Only 4 randomized studies 29-32 on NSAIDs have been conducted on VOC, and the results of those trials were contradictory, with the evidence level of NSAID efficacy also low. The authors of 2 adult and 1 pediatric controlled study compared parenteral ketorolac to placebo 29,31,32 and another diflunisal versus placebo. 30 Two of those studies 29,32 concerned single-dose administrations with short follow-up periods (4 and 6 hours, respectively), and no significant differences were found for the average opioid requirement or pain relief.…”

mentioning

confidence: 99%

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A randomized, controlled clinical trial of ketoprofen for sickle-cell disease vaso-occlusive crises in adults

Bartolucci¹,

Murr²,

Roudot‐Thoraval

et al. 2009

Blood

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Vaso-occlusive crisis (VOC) is the primary cause of hospitalization of patients with sickle-cell disease. Treatment mainly consists of intravenous morphine, which has many dose-related side effects. Nonsteroidal antiinflammatory drugs have been proposed to provide pain relief and decrease the need for opioids. Nevertheless, only a few underpowered trials of nonsteroidal antiinflammatory drugs for sickle-cell VOC have been conducted, and conflicting results were reported. We conducted a phase 3, double-blind, randomized, placebo-controlled trial with ketoprofen (300 mg/day for 5 days), a nonselective cyclooxygenase inhibitor, for severe VOC in adults. A total of 66 VOC episodes were included. The primary efficacy outcome was VOC duration. The secondary end points were morphine consumption, pain relief, and treatment failure. Seven VOC episodes in each group were excluded from the analysis because of treatment failures. No significant between-group differences were observed for the primary outcome or the secondary end points. Thus, although ketoprofen was well-tolerated, it had no significant efficacy as treatment of VOC requiring hospitalization. These findings argue against its systematic use in this setting. IntroductionPain is the most frequent manifestation of sickle-cell disease (SCD) and is thought to be a consequence of sickle-cell vaso-occlusion. Vaso-occlusive crisis (VOC) is the primary cause of hospitalization of patients with SCD and is among the main causes of death in affected adults. 1,2 To date, no specific therapeutic agents have been approved for VOC, and treatment of uncomplicated VOC is merely symptomatic: bed rest, analgesics and hydration. According to American and British recommendations,3,4 severe pain of VOC that requires hospitalization should be treated with intravenous morphine. However, pain relief is not easily obtained during episodes of VOC, and morphine has many dose-related side effects, including sedation, nausea, constipation, pruritus, and hypoventilation. In addition, it might contribute to the development of acute chest syndrome. 5 In light of these potentially severe adverse events, many physicians are still reluctant to administer high doses of potent narcotics, and many medical texts do not provide adequate information for the treatment of pain. 6 A drug that would provide pain relief in patients with SCD and decrease the need for narcotics would be of obvious benefit.According to the results of 2 trials, 7,8 corticosteroids had a potentially beneficial effect on VOC by reducing the duration of analgesics, but corticosteroids have been shown to induce recurrent pain episodes. 7-11 Pilot trials with inhaled nitric oxide 12 and poloxamer 188 13 yielded promising results but were experimental, and those treatments are not yet available for routine use.Nonsteroidal antiinflammatory drugs (NSAIDs) are an effective treatment to decrease surgical and posttraumatic pain. 14-21 NSAIDs and opioid analgesics have a synergic effect, 22 thereby achieving better pain control and an ...

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

“…[29][30][31][32] Those studies included small numbers of patients and obtained conflicting results. Moreover, the use of NSAIDs in patients with SCD raises other concerns.…”

Section: Introductionmentioning

confidence: 99%

mentioning

confidence: 99%

See 2 more Smart Citations

A randomized, controlled clinical trial of ketoprofen for sickle-cell disease vaso-occlusive crises in adults

Bartolucci¹,

Murr²,

Roudot‐Thoraval

et al. 2009

Blood

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“…Single-dose parenteral ketorolac did not reduce opioid requirements in painful vaso-occlusive crisis (Wright et al, 1992 Level II; Hardwick et al, 1999 Level II).…”

Section: Nsnsaidsmentioning

confidence: 96%

Safety of opioid patch initiation in Australian residential aged care

Gadzhanova

Roughead

Pont

2015

Medical Journal of Australia

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Objective: To explore opioid use by aged care facility residents before and after initiation of transdermal opioid patches. Design: A cross‐sectional cohort study, analysing pharmacy data on individual patient supply between 1 July 2008 and 30 September 2013. Setting: Sixty residential aged care facilities in New South Wales. Participants: Residents receiving an initial opioid patch during the study period. Main outcome measure: The proportion of residents who were opioid‐naive in the 4 weeks prior to patch initiation was determined. In addition, the patch strength at initiation and the daily dose of transdermal patches and of additional opioids 1 month after initiation were determined. Results: An opioid patch was initiated in 596 of 5297 residents (11.3%: 2.6% fentanyl, 8.7% buprenorphine) in the 60 residential aged care facilities. The mean age at initiation was 87 years, and 74% of the recipients were women. The proportion of recipients who were opioid‐naive before patch initiation was 34% for fentanyl and 49% for buprenorphine. Most were initiated at the lowest available patch strength, and the dose was up‐titrated after initiation. Around 15% of fentanyl users and 10% of buprenorphine users needed additional regular opioids after patch initiation. Conclusions: The results suggest some inappropriate initiation of opioid patches in Australian residential aged care facilities. Contrary to best practice, a third of residents initiated on fentanyl patches were opioid‐naive in the 4 weeks before initiation.

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Intravenous Ketorolac in the Emergency Department Management of Sickle Cell Pain and Predictors of Its Effectiveness

Hk²,

Cr³

et al. 2001

Arch Pediatr Adolesc Med

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Ketorolac for sickle cell vaso-occlusive crisis pain in the emergency department: lack of a narcotic-sparing effect

Cited by 50 publications

References 17 publications

A randomized, controlled clinical trial of ketoprofen for sickle-cell disease vaso-occlusive crises in adults

A randomized, controlled clinical trial of ketoprofen for sickle-cell disease vaso-occlusive crises in adults

Safety of opioid patch initiation in Australian residential aged care

Intravenous Ketorolac in the Emergency Department Management of Sickle Cell Pain and Predictors of Its Effectiveness

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