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Cost effectiveness analysis of intravenous ketorolac and morphine for treating pain after limb injury: double blind randomised controlled trial

BMJ 2000; 321 doi: https://doi.org/10.1136/bmj.321.7271.1247 (Published 18 November 2000) Cite this as: BMJ 2000;321:1247

Ketorolac and cancer pain

Dear Sir,

Many of the issues explored by the Rainer et al, in the acute
emergency department setting, are also relevant to other settings such as
the palliative care (1).

Morphine remains the gold standard in cancer patients with moderate
to severe pain. Despite the prophylactic use of laxatives and antiemetics,
morphine is often associated with many unpleasant side effects. These side
effects such as constipation, nausea, sedation etc., impair the quality of
life of the patients but the side effects are often overlooked by
physicians (2). Cancer pain, unfortunately, is also opioid resistant in
some situations (2).

Ketorolac has been shown to be effective in morphine-resistant pain
and also has morphine sparing effect (3) (4) (5). It can be given through
various routes including continuous subcutaneous infusion (3). In spite of
the evidence available, ketorolac and other parentral NSAIDS are under-
used in cancer patients.

A significant percentage of cancer patients are admitted to the
oncology and palliative care wards for pain relief. The regular oral
intake of medications by these patients is often poor. This is partly due
to the local and systemic effects of advanced cancer itself, and partly
due to the side effects of chemotherapy and radiotherapy.

An increase in use of ketorolac and other parentral NSAIDS, as a
primary as well as opioid adjunctive analgesia, would be potentially cost
effective in these settings. This practice could reduce the length of
hospital stay because of better pain relief and smaller number of opioid
related adverse events resulting from morphine dose reduction. Needless to
say, that the quality of life would be better for patients.

Ref:

(1) 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.

(2) Ahmedzai S. New approaches to pain control in patients with
cancer. Eur J Cancer.1997; 33 Suppl 6:S8-14, 1997.

(3) Myers KG, Trotman IF. Use of ketorolac by continuous
subcutaneous infusion for the control of cancer-related pain. Postgrad Med
J.1994; 70(823): 359-62.

(4) Staquet M, De wasch G. A double blind comparison of multiple dose
regimen ketorolac and buprenorphine in patients with cancer pain. Pain
1990;suppl 15: s353.

(5) Joishy SK. Walsh D. The opioid-sparing effects of intravenous
ketorolac as an adjuvant analgesic in cancer pain: application in bone
metastases and the opioid bowel syndrome. J Pain Symptom Manage. 16(5):
334-9, 1998

Competing interests: No competing interests

18 December 2000
Sundar Santhanam
Specialist Registrar in Oncology
Dept. of Oncology, Osborne Building, Leicester Royal Infirmary, Leicester LE1 5WW.