FPIN's Help Desk Answers
Ketorolac vs. Morphine for Pain Relief After Fractures
Am Fam Physician. 2020 Apr 15;101(8):495-496.
In emergency department settings, is parenteral ketorolac superior to morphine for achieving timely pain reduction in patients with acute long bone fractures?
Parenteral ketorolac is as effective as parenteral morphine for short-term pain relief in patients with long bone fractures, and it results in fewer adverse effects. (Strength of Recommendation [SOR]: B, based on two randomized controlled trials [RCTs].) Ketorolac is slightly more effective than morphine for pain relief during limb motion. (SOR: B, based on a single RCT.)
An RCT (N = 148) published in 2000 compared parenteral ketorolac with parenteral morphine for pain control in patients presenting to the emergency department with long bone fractures.1 Patients 16 years and older with a limb injury and no other disqualifying factors (e.g., history of substance abuse, dementia, indigestion, peptic ulcers, renal failure, known drug hypersensitivity) were included in the study. Patients were given a loading dose of ketorolac or morphine on presentation (10 mg or 5 mg, respectively), followed by additional doses (5 mg or 2.5 mg, respectively) every five to 20 minutes. The primary outcome of pain reduction was assessed by a zero- to 10-point visual analog scale (VAS), with a score of 10 indicating maximal pain. Pain was assessed at baseline, then every five minutes for the first 30 minutes, every 30 minutes for the next 90 minutes, then once more six hours after the initial injection. Compared with ketorolac, morphine administration nonsignificantly increased the likelihood of pain reduction when the injured limb was at rest. However, ketorolac administration increased the likelihood of pain reduction when the limb was moved (hazard ratio = 1.5; 95% CI, 1.1 to 2.1). At rest, the median decrease in pain score per hour did not differ significantly between the groups (11.4 vs. 10.8; P = .5). However, with activity, the median decrease favored ketorolac (1.1 vs. 0.87; P
1. Rainer TH, Jacobs P, Ng YC, 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):1247–1251.
2. Masoumi B, Farzaneh B, Ahmadi O, et al. Effect of intravenous morphine and ketorolac on pain control in long bone fractures. Adv Biomed Res. 2017;6:91.
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