title: Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial.
abstract: OBJECTIVE
  Nonsteroidal anti-inflammatory drugs are used extensively for the management of acute and chronic pain, with ketorolac tromethamine being one of the most frequently used parenteral analgesics in the emergency department (ED). The drugs may commonly be used at doses above their analgesic ceiling, offering no incremental analgesic advantage while potentially adding risk of harm. We evaluate the analgesic efficacy of 3 doses of intravenous ketorolac in ED patients with acute pain.
  
  
  METHODS
  We conducted a randomized, double-blind trial to assess the analgesic efficacy of 3 doses of intravenous ketorolac (10, 15, and 30 mg) in patients aged 18 to 65 years and presenting to the ED with moderate to severe acute pain, defined by a numeric rating scale score greater than or equal to 5. We excluded patients with peptic ulcer disease, gastrointestinal hemorrhage, renal or hepatic insufficiency, allergies to nonsteroidal anti-inflammatory drugs, pregnancy or breastfeeding, systolic blood pressure less than 90 or greater than 180 mm Hg, and pulse rate less than 50 or greater than 150 beats/min. Primary outcome was pain reduction at 30 minutes. We recorded pain scores at baseline and up to 120 minutes. Intravenous morphine 0.1 mg/kg was administered as a rescue analgesic if subjects still desired additional pain medication at 30 minutes after the study drug was administered. Data analyses included mixed-model regression and ANOVA.
  
  
  RESULTS
  We enrolled 240 subjects (80 in each dose group). At 30 minutes, substantial pain reduction was demonstrated without any differences between the groups (95% confidence intervals 4.5 to 5.7 for the 10-mg group, 4.5 to 5.6 for the 15-mg group, and 4.2 to 5.4 for the 30-mg group). The mean numeric rating scale pain scores at baseline were 7.7, 7.5, and 7.8 and improved to 5.1, 5.0, and 4.8, respectively, at 30 minutes. Rates of rescue analgesia were similar, and there were no serious adverse events. Secondary outcomes showed similar rates of adverse effects per group, of which the most common were dizziness, nausea, and headache.
  
  
  CONCLUSIONS
  Ketorolac has similar analgesic efficacy at intravenous doses of 10, 15, and 30 mg, showing that intravenous ketorolac administered at the analgesic ceiling dose (10 mg) provided effective pain relief to ED patients with moderate to severe pain without increased adverse effects.
authors.affiliation: Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY. Electronic address: smotov@maimonidesmed.org.
authors.forename: Sergey
authors.initials: S
authors.lastname: Motov
authors.affiliation: Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY.
authors.forename: Matthew
authors.initials: M
authors.lastname: Yasavolian
authors.affiliation: Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY.
authors.forename: Antonios
authors.initials: A
authors.lastname: Likourezos
authors.affiliation: Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY.
authors.forename: Illya
authors.initials: I
authors.lastname: Pushkar
authors.affiliation: Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY.
authors.forename: Rukhsana
authors.initials: R
authors.lastname: Hossain
authors.affiliation: Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY.
authors.forename: Jefferson
authors.initials: J
authors.lastname: Drapkin
authors.affiliation: Department of Pharmacy, New York City Health + Hospitals, Brooklyn, NY.
authors.forename: Victor
authors.initials: V
authors.lastname: Cohen
authors.affiliation: Department of Pharmacy, Maimonides Medical Center, Brooklyn, NY.
authors.forename: Nicholas
authors.initials: N
authors.lastname: Filk
authors.affiliation: Department of Pharmacy, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY.
authors.forename: Andrew
authors.initials: A
authors.lastname: Smith
authors.affiliation: Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY.
authors.forename: Felix
authors.initials: F
authors.lastname: Huang
authors.affiliation: Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY.
authors.forename: Bradley
authors.initials: B
authors.lastname: Rockoff
authors.affiliation: Office of Research Administration, Maimonides Medical Center, Brooklyn, NY; Department of Medicine, Albert Einstein College of Medicine, Bronx, NY.
authors.forename: Peter
authors.initials: P
authors.lastname: Homel
authors.affiliation: Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY.
authors.forename: Christian
authors.initials: C
authors.lastname: Fromm
mesh_terms: D059787:Acute Pain / Q000188:drug therapy* / Q000503:physiopathology; D000328:Adult; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000008:administration & dosage* / Q000494:pharmacology / Q000627:therapeutic use*; D004305:Dose-Response Relationship, Drug; D004311:Double-Blind Method; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D007275:Injections, Intravenous; D020910:Ketorolac / Q000008:administration & dosage* / Q000494:pharmacology / Q000627:therapeutic use*; D008297:Male; D010147:Pain Measurement; D016896:Treatment Outcome
chemical_list: D000894:Anti-Inflammatory Agents, Non-Steroidal; D020910:Ketorolac