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Am Fam Physician. 2017;96(4):262

Clinical Question

Are lower doses of ketorolac as effective as standard doses for acute pain control in patients presenting to the emergency department?

Bottom Line

A 10-mg dose of ketorolac is as effective as higher doses for the short-term treatment of acute pain for patients in the emergency department. (Level of Evidence = 1b)

Synopsis

Ketorolac is a nonsteroidal anti-inflammatory drug available in parenteral form for the treatment of acute pain. Although higher doses are often used, ketorolac may have a therapeutic ceiling of 10 mg. To investigate the effectiveness of lower doses of ketorolac, these investigators used a convenience sample of patients presenting to the emergency department on weekdays between 8:00 a.m. and 8:00 p.m. to enroll those with acute flank, abdominal, musculoskeletal, or headache pain rated at least 5 on a 10-point rating scale. The authors excluded patients with unstable vital signs, active peptic ulcer disease or gastrointestinal bleeding, or history of liver or renal disease, and those who were pregnant or breastfeeding. Using concealed allocation, investigators randomized 240 patients to receive a 10-mg, 15-mg, or 30-mg dose of ketorolac. Patients who still required pain medication 30 minutes after administration of the study drug received intravenous morphine at a dose of 0.1 mg per kg.

The three groups were similar at baseline: All groups had a mean age of 40 years, two-thirds of patients were women, and the baseline pain score was between 7 and 8. Analysis was by intention to treat. The primary outcome was a reduction of pain scores at 30 minutes after administration of the study drug. In all three groups, there was a significant decrease in pain scores from baseline to 30 minutes by at least two points. However, there were no significant differences in reduction of pain scores across the three groups at 30 minutes, or at subsequent time points of 60, 90, and 120 minutes. Further, there were no differences in the use of rescue morphine analgesia among the three groups. The most common adverse effects reported were dizziness, nausea, and headache, and they were similar in all three groups.

Study design: Randomized controlled trial (double-blinded)

Funding source: Government

Allocation: Concealed

Setting: Emergency department

Reference:Motov S, Yasavolian M, Likourezos A, et al. Comparison of intravenous ketorolac at three single-dose regimens for treating acute pain in the emergency department: a randomized controlled trial [published online ahead of print December 16, 2016]. Ann Emerg Med. http://www.sciencedirect.com/science/article/pii/S0196064416312446 [login required]. Accessed June 27, 2017.

POEMs (patient-oriented evidence that matters) are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, see http://www.essentialevidenceplus.com. Copyright Wiley-Blackwell. Used with permission.

For definitions of levels of evidence used in POEMs, see http://www.essentialevidenceplus.com/product/ebm_loe.cfm?show=oxford.

To subscribe to a free podcast of these and other POEMs that appear in AFP, search in iTunes for “POEM of the Week” or go to http://goo.gl/3niWXb.

This series is coordinated by Sumi Sexton, MD, editor-in-chief.

A collection of POEMs published in AFP is available at https://www.aafp.org/afp/poems.

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