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EDITORIALS: George A Jelinek Ketorolac versus morphine for severe pain BMJ 2000; 321: 1236-1237 [Full text]

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KETOROLAC ALSO IN MEDICAL CAUSES OF SEVERE PAIN?

Srikant Gadwalkar   (19 November 2000)

ketorolac - as safe as proposed?

John Peacock   (22 November 2000)

KETOROLAC ALSO IN MEDICAL CAUSES OF SEVERE PAIN? 19 November 2000
Srikant Gadwalkar, ASST PROF IN MEDICINE VIMS, BELLARY. INDIA Send response to journal: Re: KETOROLAC ALSO IN MEDICAL CAUSES OF SEVERE PAIN?	IT is interesting to note that ketorolac is as effective as morphine the gold standard without the side effect of respiratory depression.We have tried ketorolac aslo im medical causes like AMI, and we have fund it very effective but not as good as morphine in relieving pain of Acute Myocardial Infarction.If pain is not relieved after ketoralac can we use morphine again? Will it not have any ADR or interaction? If the actions of the two is additive can we combine ketorolac and morphine and have superior analgesic with lesser side effect of respiratory depression and addiction.
ketorolac - as safe as proposed? 22 November 2000
John Peacock, consultant anaesthetist Royal Hallamshire Hospital, Sheffield Send response to journal: Re: ketorolac - as safe as proposed?	Editor. The editorial by Jelinek (1) in response to the paper by Rainer et al (2) suggests that intravenous ketorlac will become the analgesic of choice for many emergencies. Both the original paper and the editorial suggest that the side-effects of ketorolac are fewer and the drugs are equally cost-effective. Jelinek recognised that renal problems can occur but stated that they usually resolve when the drug is stopped and should not be an important problem in short term treatment. The original authors make no comment about the possiblity of renal effects other than listing renal failure in the exclusion criteria. Having peronally seen renal failure following ketorolac injection I would want to encourage a degree of caution in line with the product information for the drug. This states that great care should be taken when administering the drug in certain patients, namely the elderly, those with renal impairment and those with the risk of hypovolaemia; ketorolac injection is also contraindicated in those who will undergo surgery because of possible platelet effects. It is unclear how renal impairment was identified in the original study. However administration of a potent NSAID to elderly patients, the mean age of the group was 53.9 years (SD 21.7), with fractures where hypovolaemia may be present, without confirming renal function by measuring the creatinine concentration is likely to result in renal impairment in some patients eventually. The Royal College of Anaesthetists have produced excellent guidelines for the use of NSAID's in the perioperative period (3). Within the evidence which they reviewed (4), the Council for the International Organisation of Medical Sciences noted 238 renal adverse events related to ketorolac between 1990 and 1994 which constituted 12.5% of the total adverse events for this drug at that time. Of 97 fatal reactions to ketorolac reported worldwide 20.6% included renal failure. Whilst ketorlac is undoubtedly an effective analgesic and does have advantages over morphine, care should be exercised in extrapolating any conclusions outside of the original study population and great care should be taken in its use (as with other NSAID's) where renal impairement may occur. 1. Jellinek GA. Ketorolac versus morphine for severe pain. BMJ 2000;321:1236-7. (18 November.) 2. Rainer TH, Jacobs P, Ng YC, Cheung NK, Tam M, Lam PKW, et al. Cost effectiveness analysis of intravenous ketorolac and morphine for treating pain after limb injury: double blind randomised controlled trial. BMJ 2000;321:1247-51. 3. Royal College of Anaesthetists. Guidelines for the use of Non-steriodal Anti-inflammatory Drugs in the Perioperative Period. March 1998. 4. Summers K, Wilson R. Ketorolac injection: a review of its safety and rational use in day case and major surgery. Pharmaceutical Medicine 1994;8:115-34.