KETOROLAC TROMETHAMINE

KETOROLAC TROMETHAMINE (ke-tor'o-lac) Toradol, Acular, Acular LS Classifications: analgesic, nonsteroidal antiinflammatory drug (nsaid); antipyretic; Therapeutic:nsaid, analgesic; antipyretic Prototype: Ibuprofen Pregnancy Category: B

Availability

10 mg tablets; 15 mg/mL, 30 mg/mL injection; 0.4%, 0.5% ophthalmic solution

Action

It inhibits synthesis of prostaglandins by inhibiting both COX-1 and COX-2 enzymes. Is a peripherally acting analgesic.

Therapeutic Effect

Exhibits analgesic, antiinflammatory, and antipyretic activity. Effective in controlling acute post-operative pain.

Uses

Short-term management of pain; ocular itching due to seasonal allergic conjunctivitis, reduction of post-operative pain and photophobia after refractive surgery.

Contraindications

Hypersensitivity to ketorolac; individuals with complete or partial syndrome of nasal polyps, angioedema, and bronchospastic reaction to aspirin or other NSAIDs; during labor and delivery; patients with severe renal impairment or at risk for renal failure due to volume depletion; patients with risk of bleeding; active peptic ulcer disease; pre- or intraoperatively; intrathecal or epidural administration; in combination with other NSAIDs.

Cautious Use

History of peptic ulcers; impaired renal or hepatic function; older adults; debilitated patients; diabetes mellitus; SLE; CHF; pregnancy (category B); children under 2 years; children under 3 years with ophthalmic solution.

Route & Dosage

Pain Adult: IV Loading Dose 30 mg (15 mg <50 kg) IM 30–60 mg loading dose, then 15–30 mg q6h [max: 150 mg/d on first day, then 120 mg subsequent days (30 mg load, then 15 mg q6h if <50 kg)] PO 10 mg q6h prn (max: 40 mg/d) max duration all routes 5 d Geriatric: IV Loading Dose 15 mg IM 30 mg loading dose, then 15 mg q6h PO 5–10 mg q6h prn (max: 40 mg/d) max duration all routes 5 d Pain after Refractive Surgery Adult: Ophthalmic Acular LS only 1 drop in operative eye q.i.d. up to 4 d Allergic Conjunctivitis Adult: Ophthalmic 1 drop 0.5% solution q.i.d.

Administration

WARNING: Do not administer IV, IM, or PO ketorolac longer than 5 d.

Oral

• Give with food to reduce GI effects.

Instillation

• Do not touch container to the eye when applying ophthalmic drops.

Intramuscular

• Inject IM drug slowly and deeply into a large muscle.
• Rotate injection sites to avoid injection site pain in patients receiving multiple doses.

Intravenous PREPARE: Direct: Give undiluted.   ADMINISTER: Direct: Give IV bolus dose over at least 15 sec. Preferred method is to give through a Y-tube in a free-flowing IV.   INCOMPATIBILITIES Solution/additive: Haloperidol, hydroxyzine, meperidine, morphine, prochlorperazine, promethazine. Y-site: Azithromycin, fenoldopam.

• Store all forms at 15°–30° C (59°–86° F).

Adverse Effects (≥1%)

CNS: Drowsiness, dizziness, headache. GI: Nausea, dyspepsia, GI pain, hemorrhage. Other: Edema, sweating, pain at injection site.

Interactions

Drug: May increase methotrexate levels and toxicity; may increase lithium levels and toxicity. Herbal: Feverfew, garlic, ginger, ginkgo increased bleeding potential.

Pharmacokinetics

Peak: 45–60 min. Distribution: Into breast milk. Metabolism: In liver. Elimination: In urine. Half-Life: 4–6 h.

Nursing Implications

Assessment & Drug Effects

• Correct hypovolemia prior to administration of ketorolac.
• Lab tests: Periodic serum electrolytes and liver functions; urinalysis (for hematuria and proteinuria) with long-term use.
• Monitor urine output in older adults and patients with a history of cardiac decompensation, renal impairment, heart failure, or liver dysfunction as well as those taking diuretics. Discontinuation of drug will return urine output to pretreatment level.
• Monitor for S&S of GI distress or bleeding including nausea, GI pain, diarrhea, melena, or hematemesis. GI ulceration with perforation can occur anytime during treatment. Drug decreases platelet aggregation and thus may prolong bleeding time.
• Monitor for fluid retention and edema in patients with a history of CHF.

Patient & Family Education

• Watch for S&S of GI ulceration and bleeding (e.g., bloody emesis, black tarry stools) during long-term therapy.
• Note: Possible CNS adverse effects (e.g., light-headedness, dizziness, drowsiness).
• Do not drive or engage in potentially hazardous activities until response to drug is known.
• Do not use other NSAIDs while taking this drug.

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Common adverse effects in italic, life-threatening effects underlined; generic names in bold; classifications in SMALL CAPS; Canadian drug name; Prototype drug