Ketorol (for injection), 10 pcs., 1 ml, 30 mg/ml, solution for intravenous and intramuscular administration

Compound

Composition of tablets: ketorolac (10 mg/tablet), MCC, lactose, corn starch, colloidal silicon dioxide, Mg stearate, Na carboxymethyl starch (type A).
The film shell contains: hypromellose, propylene glycol (additive E1520), titanium dioxide; dyes brilliant blue (22%) and quinoline yellow (78%) - olive green.

Composition of the solution: ketorolac (30 mg per milliliter), octoxynol, EDTA, Na chloride, ethanol, propylene glycol (additive E1520), Na hydroxide, water for injection.

Gel composition: ketorolac (20 mg per gram of gel), propylene glycol (additive E1520), dimethyl sulfoxide, carbomer 974P, Na methyl and propyl parahydroxybenzoate, tromethamine (trometamol), Drimon Inde flavoring, ethanol, glycerol, purified water.

Release form

• Tablets in p/o 10 mg, package No. 20. Ketorol tablets (INN - Ketorolac) are biconvex, round in shape, covered with a green coating (the core is white or close to white). On one side there is an imprint in the shape of the letter “S”.
• Solution for IM and IV administration 30 mg/ml, package No. 10. Ketorol injections are available in 1 ml ampoules, each of which has a breaking point and a ring in the upper part.
• Gel 2% for external use, tubes 30 g, packaging No. 1. Ketorol gel is a homogeneous, characteristically smelling, transparent (or translucent) substance.

Ketorolac in the relief of renal colic

Ketorolac is widely used for the successful relief of renal colic. This is due to the fact that this drug, by blocking the synthesis of prostaglandins in the kidney, reduces urinary tract motility and spasm, reducing pressure in the urinary tract, as well as reducing renal blood flow [18]. It has been shown that intravenous administration of 30 mg of ketorolac for renal colic gives the same analgesic effect as intravenous administration of 2.5 g of metamizole in combination with antispasmodics with fewer side effects [19]. According to a double-blind randomized study that included 57 patients with renal colic, the analgesic activity of ketorolac (30 mg intramuscularly) and diclofenac (75 mg intramuscular) was comparable in severity and duration [20]. Similar data were obtained in another double-blind controlled study [21]. In a study involving 48 patients with renal colic, intramuscular administration of 30 mg ketorolac was more effective than subcutaneous administration of tramadol at a dose of 1 mg/kg body weight [22].

According to a multicenter, double-blind, randomized trial that included patients 18–65 years of age with moderate to severe renal colic, ketorolac was as effective as meperedine for pain relief, but caused less functional impairment. To relieve pain, patients were initially treated with meperidine at a dose of 50 mg intravenously, then 25–50 mg every 15 minutes for complete pain relief. Another group of patients first received ketorolac (30 mg intravenously) or placebo, and then the injections were repeated every 15 minutes as needed. Overall, 64% of patients receiving meperidine and 72% of patients receiving ketorolac achieved successful pain relief at 60 minutes; 10% of patients after using meperidine and 44% of patients after ketorolac were able to resume normal activity within an hour [23].

Pharmacodynamics and pharmacokinetics

What is ketorolac?

The active substance Ketorol is a mixture in which the [+]R and [-]S enantiomers are present in equal quantities, and the analgesic effect is due to the [-]S form.

Pharmacodynamics

The drug is a powerful analgesic with anti-inflammatory properties and moderate antipyretic activity .

Its mechanism of action is associated with the ability to indiscriminately inhibit the activity of the COX 1 and 2 enzyme, mainly in peripheral tissues. As a result, the biosynthesis of Pg, a modulator of thermoregulation, pain sensitivity and inflammation, slows down.

Ketorolac does not affect opiate receptors, does not have anxiolytic or sedative effects, does not depress respiration, and does not lead to the development of drug dependence.

The analgesic effect of the drug is more pronounced in comparison with analogues. The effect of its use is comparable to the analgesic effect of morphine .

After injection into the muscle and oral administration, the pain begins to decrease after 0.5 and 1 hour, respectively. To achieve the maximum effect, it takes from 60 to 120 minutes.

Pharmacokinetics

Absorption in the digestive canal when taken orally is rapid. TSmax after taking 1 tablet on an empty stomach - 40 minutes.

Fatty foods reduce the Cmax in the blood while simultaneously increasing the TCmax up to 1 hour 40 minutes.

99% of the dose taken is bound to plasma proteins. With hypoalbuminemia, the concentration of free substance in the blood increases.

Bioavailability is one hundred percent (regardless of the method of administration of the drug).

When administered parenterally, the substance is absorbed quickly and completely.

Equilibrium concentration of Css when Ketorol is administered intravenously or intramuscularly at a dose of 120 mg/day. (4 injections of 30 mg) and when taken orally at a dose of 40 mg/day. (1 tablet in 4 doses) is achieved after 24 hours. The highest values ​​of this indicator are observed with parenteral administration of 1 ml of solution 4 times a day.

The substance passes into breast milk: when a nursing woman takes 1 tablet of Tmax ketorolac in milk - 2 hours.

More than 50% of administered ketorolac is biotransformed in the liver with the formation of pharmacologically inactive metabolites . The substance is excreted mainly in the form of glucuronic metabolites and p-hydroxyketorolac. 91% of the dose taken is excreted by the kidneys, 6% - with the contents of the intestines.

In patients with healthy kidneys, the elimination half-life averages 5.3 hours.

In older people, T1/2 lengthens, in young people it shortens.

The functional state of the liver does not affect the pharmacokinetics of the drug. In case of kidney damage, in which the plasma concentration of creatinine is 19-50 mg/l, the half-life is extended to 10.3-10.8 hours; if renal failure is more severe, this figure exceeds 13.6 hours.

It is not excreted during hemodialysis .

Why are the shapes different?

Initially, there were only two ways to deliver medicine to the body: swallowed or applied; other options were not available to doctors of the past.

But with the development of medicine, it has become clear that these options do not always work. When swallowed, the drug has a long journey to travel. Before getting to the right place, the tablet passes through the aggressive environment of the stomach. And after absorption, the substances enter the liver through the bloodstream, where toxins are neutralized and the medicine can become inactive before reaching the target organ.

Also, some drugs can negatively affect the functioning of the gastrointestinal tract. Cause nausea, vomiting or simply not work if the stomach or intestines are not in order and absorption is impaired.

“A classic example is when we changed a patient’s drug,” says GMS Clinic therapist Andrey Besedin, “during exacerbations of gastric ulcer, duodenal ulcer, or after surgery on the gastrointestinal tract. In this case, it is better to choose intramuscular or intravenous administration."

There are situations when it is necessary to administer medications intravenously. Most often this is due to urgency, but there are drugs that are destroyed in the gastrointestinal tract. For example, some antibiotics are available only in the form of injections, and in this case injections cannot be avoided.

“Any intramuscular, subcutaneous, intravenous injection is a small operation,” explains Andrey Besedin, “during which we violate the integrity of the body, skin, muscles, depending on what we do. Therefore, if possible, it is better to use tablets and capsules.”

There are medications that have serious effects on the entire body when taken in the form of tablets or injections. For such cases, local forms were invented. Thus, hormones in creams and nasal spray are useful for skin manifestations and allergic rhinitis, but the same hormones in large doses can cause serious consequences with long-term use of tablets or intravenous injections.

For children, medications are available in the form of chewable tablets, drops, or reduced-size tablets, so as not to turn every dose of medication into a battle or cause the association between treatment and pain. Unfortunately, this is not always possible, especially in children's hospitals.

“There are no unambiguous dogmas in medicine,” says Andrey Besedin, “in each situation we choose the type of drug administration individually, depending on what goals we want to achieve with a particular patient.”

Indications for use

Ketorol tablets: what does the tablet form of the drug help with?

The medicine helps reduce moderate/severe pain and inflammation, but does not affect the progression of the disease.

Tablets are effective for toothache , headaches , pain that occurs during menstruation, after injuries, in the postoperative and postpartum periods, against the background of cancer, with damage to peripheral nerves, with radiculopathy , arthralgia , myalgia , sprains, dislocations, rheumatic diseases .

What does injection medicine help with?

Ketorol in ampoules, like the tablet form of the drug, is used to relieve pain of moderate and severe intensity.

Parenteral administration of the drug is preferable in situations where it is necessary to quickly relieve pain, and also if the patient cannot take it orally (for example, with a peptic ulcer or due to the gag reflex).

Indications for use of Ketorol: what is the gel used for?

Local application of the gel helps reduce pain and inflammation in:

• injuries (inflammation and bruises of soft tissues, including after injury; bursitis , synovitis , ligament damage, epicondylitis , tendonitis );
• myalgia;
• arthralgia;
• radiculitis;
• neuralgia;
• rheumatic diseases.

What does the choice depend on?

The doctor determines the form of administration, relying not only on those drugs that are available. He pays attention to the patient’s age, gender, financial capabilities, and even his mood and attitude towards treatment. Children require special attention.

“Choosing the form of a drug is partly a creative process,” says Ekaterina Bokova, a therapist at the 120 to 80 clinic. “There are no ready-made solutions here. But most often we focus on age. If this is a very young baby, then we choose liquid or rectal forms to prevent spitting and choking. This way, the child will receive his dose of the active substance with a greater guarantee. Sometimes you even have to make a choice in favor of an injectable drug. In any case, a child should not be prescribed “adult” pills and divided into parts.”

The wishes of the patient or relatives also matter when choosing the form of the medicine. For older people, it is important to take fewer pills per day, otherwise you can get confused, especially if there are a lot of medications. In such cases, tablet holders or planners help.

“Unfortunately, older people usually insist on prescribing the most affordable drug,” says Ekaterina Bokova, “here, if possible, we will meet them halfway.”

Contraindications

Contraindications for parenteral administration and oral administration of Ketorol:

• hypersensitivity to the components of the solution/tablets;
• complete or partial combination of clinical manifestations of aspirin-induced bronchial asthma (NSAID intolerance, asthma attacks, polypous rhinosinusitis );
• the presence of erosions and ulcerative defects on the mucous membrane of the upper gastrointestinal tract;
• bleeding in the active phase (gastrointestinal, cerebrovascular or other);
• worsened inflammatory bowel disease;
• hemophilia and other pathologies of the hemostatic system;
• end stage of heart failure (decompensated heart failure);
• functional disorders or active liver disease;
• confirmed hyperkalemia ;
• postoperative period after CABG;
• renal failure , in which the creatinine does not exceed 30 ml/min, progressive kidney pathologies ;
• pregnancy , childbirth, lactation ;
• age up to 16 years.

Relative contraindications:

• congestive heart failure ;
• bronchial asthma (BA);
• IHD;
• hypersensitivity to NSAIDs;
• pathological dys- or hyperlipidemia ;
• cerebrovascular pathologies;
• arterial hypertension;
• kidney damage, in which the creatinine is below 60 ml/min;
• sepsis;
• cholestasis;
• edema syndrome;
• diabetes;
• SLE;
• chronic obliterating diseases of the arteries of the lower extremities;
• treatment with other NSAIDs, anticoagulants , antiplatelet agents , SSRIs, oral corticosteroids;
• history of ulcerative lesions of the digestive canal;
• smoking;
• old age (over 65 years);
• alcohol abuse;
• severe somatic diseases.

External use of Ketorol is contraindicated in case of hypersensitivity to any of the components of the gel, aspirin asthma , eczema , weeping dermatitis , after the 27th week of pregnancy and during lactation . The gel is not intended for the treatment of open wounds and infected abrasions. The drug is prescribed to adolescents from the age of sixteen.

Ketorol gel should be used with caution in case of hepatic porphyria (at the stage of exacerbation of the disease), severe liver/renal failure , CHF, asthma, in pregnant women (in the 1st and 2nd trimesters) and in the elderly.

Non-steroidal anti-inflammatory drug Ketorol in the treatment of pain syndromes

A drug with a mechanism of action that suppresses the activity of both forms of COX (COX-1 and COX-2) is ketorolac (international nonproprietary name), trade name Ketorol® (Dr. REDDY'S Laboratoris Ltd.). The active substance of the drug is ketorolac tromethamine [3, 4], which is a racemic mixture of (-)S- and (+)R-enantiomers, and the analgesic effect is due to the (-)S-form. The drug is rapidly absorbed, has high bioavailability (80–100%), binds to plasma proteins by 90–99%, undergoes hepatic metabolism, and is excreted by the kidneys (90%) and intestines (6%). After oral administration of 10 mg, the effect develops after 10–60 minutes, after intramuscular administration of 30 mg - after 15 minutes. The duration of action of the drug is 6–10 hours. However, due to the high risk of complications typical of NSAIDs, the period of its recommended use is limited to 5 days. In this mode, as studies have shown, the intensity of pain syndrome is reduced by 66% by the 3rd day of treatment, and by 82% by the 5th day [1, 5]. The therapeutic potential of ketorolac has been proven for all areas of urgent analgesia; in monotherapy, its effect is comparable to small doses of “hard” opioids [6]. In terms of analgesia, it is superior to other NSAIDs and is among the first-line drugs for short-term treatment of severe pain [7, 8]. The drug does not act on opioid receptors, therefore it does not cause adverse reactions from the central nervous system, respiratory depression and smooth muscle paresis, drug dependence, and does not have a sedative or anxiolytic effect [3, 4]. The significant analgesic effect of ketorolac is emphasized, comparable to the effect of narcotic analgesics [9], with a significantly lower incidence of serious adverse drug reactions, which together significantly reduces the cost of pharmacotherapy. Release forms: 1) tablets for oral administration of 10 mg, 2) solution for parenteral administration in ampoules of 30 mg / 1 ml, 3) 2% Ketorol gel for topical use (contains 20 mg of active substance). Indication for use is pain of severe and moderate severity (intended for symptomatic therapy, reducing the intensity of pain and inflammation at the time of use; does not affect the progression of the disease) of various origins and localization: trauma, toothache, pain in the postpartum and postoperative period, pain syndrome for oncological diseases, myalgia, arthralgia, neuralgia, radiculitis, dislocations, sprains, rheumatic diseases. When applied topically, Ketorol gel causes a weakening or disappearance of pain at the site of its application, incl. pain in the joints at rest and during movement, reduces morning stiffness and swelling of the joints [3, 4]. The drug Ketorol gel should be prescribed with caution to elderly people and pregnant women (I and II trimesters). Studies on the use of ketorolac in urgent conditions The results of a prospective multicenter study conducted in 49 clinics in 8 European countries showed [10] that ketorolac is highly effective in relieving acute pain syndromes after surgery (orthopedic, abdominal, gynecological, urological, plastic surgery) . A comparative analysis of the effectiveness and safety of ketorolac with diclofenac and ketoprofen included the results of treatment of 11,245 patients. It was found that the incidence of adverse drug reactions when taking ketorolac (90 mg/day for 2 days parenterally, then 40 mg/day for 7 days) did not differ in comparison with that when using diclofenac (150 mg/day for 2 days parenterally, then 150 mg/day for 7 days). mg/day for 7 days) or ketoprofen (200 mg/day for 2 days parenterally, then 200 mg/day for 7 days). At the same time, the risk of developing gastrointestinal bleeding and allergic reactions was significantly lower in patients taking ketorolac compared to the comparison group (diclofenac, ketoprofen). The Department of Surgery at the University of British Columbia Hospital (Vancouver, Canada) conducted a multicenter, double-blind, randomized study to compare the rate and extent of the onset of analgesic effect and the patient's functional status with a single IV dose of ketorolac and dose titration of meperidine, as well as the occurrence of adverse events [11] . This study looked at patients aged 18–65 years with moderate to severe renal colic. They were divided into 2 groups, comparable by gender and age, race and other parameters. Patients in the meperidine group received 50 mg IV at time zero, then 25–50 mg every 15 minutes. to relieve ongoing pain. Patients in the ketorolac group received 30 mg IV at time zero and placebo injections every 15 minutes. as needed. The level of pain and adverse events were assessed every 15 minutes, functional status - after 60 minutes. The main criterion for the effectiveness of the drug was the reduction of pain to moderate or its disappearance after 60 minutes. Adequate pain relief was experienced by 72% of patients receiving ketorolac and 64% of patients receiving meperidine; 44% of patients receiving ketorolac and 10% of patients receiving meperidine were able to resume normal activities after 60 minutes. The authors concluded that single IV administration of ketorolac at study doses for the relief of acute renal colic is equally effective as IV titration of meperidine and causes less functional impairment. Thus, ketorolac has been shown to be an effective drug for the treatment of renal colic, does not require close patient monitoring and does not cause adverse sedation. A comparative study conducted at the Department of Head and Neck Surgery at Loyola University Hospital (Maywood, USA) [12] assessed the efficacy and safety (risk of bleeding) of intravenous ketorolac 30 mg postoperatively in patients undergoing primary endoscopic surgery. paranasal sinuses (septum surgery), compared with the effectiveness and safety of 25 mcg fentanyl. The level of postoperative pain was recorded at 0, 30 and 60 minutes. on a visual analogue scale (VAS). Patients received fentanyl and hydrocodone/acetaminophen as needed (if pain was not sufficiently relieved). Questionnaires assessing postoperative bleeding were completed on the 1st and 7th postoperative days. 34 patients were observed, of which 16 received IV ketorolac, 18 received fentanyl. There were no significant differences in the groups when assessing pre- and postoperative hemoglobin levels, the appearance of bleeding, the severity of pain according to VAS, or the number of doses of additional analgesics. Thus, ketorolac administered intravenously was a safe analgesic during endoscopic surgery of the paranasal sinuses, because There was no increased risk of bleeding or acute posthemorrhagic anemia. The analgesic effect of IV administration of ketorolac is comparable to the effect of IV administration of fentanyl. Another study, conducted in the Department of Urology at Howard University Hospital (Washington, USA), assessed the degree of analgesic effect of 60 mg ketorolac administered intravenously during outpatient transrectal ultrasound examination and prostate biopsy [13]. The prospective study involved 24 patients who were randomized into 2 groups: Group 1 received 60 mg of ketorolac intravenously before the procedure, Group 2 (control) received no anesthesia. The number of biopsies performed, in which patients were able to withstand the entire procedure, was significantly lower in the control group than in the group that received IV ketorolac. In contrast, pain levels in patients receiving IV ketorolac were significantly lower than in patients without pain relief. Thus, intravenous administration of ketorolac significantly reduces pain during a painful procedure in full and allows patients to tolerate it more easily. Application of Ketorol in dental surgery E.A. Bazikian et al. (2005) conducted a comparative study to evaluate the effectiveness of the drug Ketorol in relieving pain in 30 patients (15–59 years) [14]. To relieve pain, Ketorol was prescribed 30 minutes in advance. before surgery IM in a single dose of 30 mg. In the following days (if necessary), Ketorol was prescribed per os at a dose of 10 mg. The daily dose did not exceed 40 mg. The total duration of use of Ketorol was determined by the need to relieve pain by the patients themselves and did not exceed 2 days (in patients undergoing implantation, Ketorol was used once 30 minutes before surgery). Thus, the studies have shown that Ketorol provides fairly reliable and adequate pain relief in the postoperative period. The authors concluded that Ketorol is safe when prescribed for prophylactic purposes (i.e., before pain syndrome), promoting a painless course of the postoperative period, and recommend including it as a permanent component of premedication. O.A. Egorova (2009) conducted a study to evaluate the effectiveness of Ketorol in relieving pain after dental surgery in outpatient practice [15]. The study included 40 patients (19–50 years old) who were treated in a dental surgery office. The first dose of Ketorol (10 mg) was immediately after surgery (against the background of the action of the anesthetic). The maximum intensity of the pain syndrome was recorded 1–2 hours after the operation; no increase in the intensity of the pain syndrome was observed while taking Ketorol. In case of pain syndrome, patients were recommended to continue taking Ketorol at a dose of 10 mg, but not more than 40 mg/day. The average daily dose of the drug was 20 mg. The course of taking Ketorol among those observed did not exceed 2 days. Thus, this study demonstrated the effectiveness of Ketorol as a powerful analgesic during a short course of use in patients after dental surgery and demonstrated its safety. A.A. Timofeev et al. (2012) provided a comparative description of non-narcotic analgesics – ketorolac and dexketoprofen, used in maxillofacial surgery for postoperative pain relief for patients [6]. 155 patients were examined: Group I (n=72) – after maxillofacial surgical interventions (removal of osteoblastomas and jaw cysts); Group II (n=40) – with open fractures of the body of the lower jaw; Group III (n=43) – with inflammatory diseases of the soft tissues of the maxillofacial region and neck (abscesses and phlegmon in patients with drug addiction). On the 1st day after surgery, ketorolac was prescribed intramuscularly at 10–20 mg every 8 hours (3 times a day), on the 2nd–3rd day – 10–20 mg every 12 hours (2 times a day). ), and on days 4–5 – 10 mg 2 times a day. On the 1st day after the operation, in patients of group I (n=27), severe pain (6–7 points) was observed in 46.8% of cases, moderate pain (4–5 points) – in 53.2%; on the 5th day, postoperative pain of low intensity was noted in 42.6%, pain was absent in 57.4% of cases. In group II, ketorolac was prescribed (n=20) according to the following regimen: in the first 2 days – 10–20 mg p/o or intramuscularly every 8 hours (3 times/day), on days 3–5 – p/o o 10 mg every 12 hours (2 times/day). After 30–45 min. after the first dose, a significant decrease in pain response was observed. In group III, ketorolac was prescribed (n=22) according to the following regimen: in the first 2–3 days of treatment intramuscularly, from the 3rd–4th day - po, on the 4th day after opening the purulent-inflammatory focus no pain was noted . Patients taking ketorolac had a more pronounced and prolonged analgesic effect compared to dexketoprofen, and the least number of side effects. Thus, ketorolac can be recommended for use in the postoperative period after removal of tumor-like and tumor formations of the jaws, for fractures of the lower jaw, after opening abscesses and phlegmons in patients burdened with drug addiction [6]. Ketorolac in the treatment of diseases of the musculoskeletal system The main goal of the treatment of acute nonspecific pain in the lumbosacral spine is, first of all, pain relief. Therapy is focused on drugs from the NSAID group with the most effective risk/benefit ratio, of which the sequential use of Ketorol and Nise currently deserves special attention. A pain relief regimen was proposed: if necessary, prolong therapy, switching to Nise 200 mg/day, 7–10 days is possible (Fig. 1) [1]. E.A. Galushko et al. (2008) conducted an open, controlled, randomized comparative study with similar forms of diclofenac sodium [16]. An assessment was made of the clinical effectiveness and tolerability of 2 dosage forms of Ketorol (tablets and solution for injection) in patients with osteoarthritis (OA) of the knee joint with severe pain. The study included 109 patients: the main group consisted of 51 patients with gonarthrosis, of which 25 received the tablet form of Ketorol (10 mg 2 times a day), 26 received the injection form (1 ml - 30 mg once); The control group consisted of 58 patients who received diclofenac (50 mg 2 times a day or 3 ml - 75 mg once). An assessment of the short-term effectiveness of the therapy showed that Ketorol is not only not inferior to diclofenac in the effectiveness of pain suppression in OA, but also exceeds it in the severity of pain relief by 25–30%. Good effectiveness (according to doctors) was noted already in the first 3 days of using Ketorol and was detected in more than half of the patients, while when using diclofenac - in 17% of those receiving tablets and in 36% of those receiving injections. In 9.8% of cases, adverse events were noted: dyspepsia and epigastric pain, and in 1.9% - an allergic reaction. To assess the safety of the drug, the levels of liver enzymes (ALT, AST), creatinine and hemoglobin in the blood were determined in all patients. The indicators were assessed during the initial examination and 5 days after starting Ketorol. The levels of the above laboratory parameters did not change significantly and remained normal throughout the study, which indirectly indicates the absence of side effects of the drug on kidney, liver and blood function. The presented results indicate the high analgesic effectiveness of Ketorol for gonarthrosis [16]. According to data provided by A. Garkavi et al. (2009), when relieving acute pain syndrome in patients with pathology of the musculoskeletal system in the early post-traumatic and postoperative periods, the effectiveness of Ketorol on the 1st day is not inferior to the effectiveness of tramadol, which is accompanied by fewer side effects [17]. ON THE. Szostak et al. (2006) provide data that the administration of Ketorol to patients with various pathologies in the clinic of internal medicine made it possible to completely relieve pain in 20% of patients, significantly reduce the severity of pain in 55% and reduce the severity of pain in 25% [5] . Based on the data obtained, the authors classified Ketorol as one of the effective and safe drugs used in the complex treatment of diseases of internal organs (pleuropneumonia, chronic non-calculous cholecystitis, urolithiasis, etc.) complicated by pain. According to the data given in the article by V.V. Skvortsova et al. (2011), after intramuscular administration of ketorolac, the maximum concentration in the blood plasma is achieved after 15–60 minutes. [18]. The drug is administered in a dose of 10–30 mg every 4–6 hours, depending on the severity of the pain syndrome. Ketorolac should be prescribed at the minimum effective dose. The maximum daily dose for adult patients under 65 years of age should not exceed 90 mg, for patients over 65 years of age or with impaired renal function - 60 mg. The maximum duration of parenteral use of the drug is 5 days. When transferring a patient from parenteral administration to oral administration, the total daily dose of ketorolac in both dosage forms on the day of transfer should not exceed 90 mg for patients under 65 years of age and 60 mg for patients over 65 years of age or with impaired renal function. In this case, the dose of the drug in tablets on the day of transition should not be more than 30 mg. Orally, 10 mg is prescribed every 4–6 hours (no more than 4 tablets/day, the maximum daily dose should not exceed 40 mg). Ketorolac in the outpatient practice of G.I. Bragina et al. (2006) in outpatient practice studied the effectiveness and safety of Ketorol in patients with acute pain syndrome of various origins [19]. The study was conducted in clinics No. 37, 56, 102 of the Moscow Department of Health and in clinic No. 3 of the Central Clinical Hospital of the Russian Academy of Sciences. 95 patients were observed (mean age: 54.6±10.6 years). The pain syndrome in patients was caused by arthropathy, dorsopathies, spondylopathy, soft tissue lesions, injuries of the musculoskeletal system, etc. In 36% of patients, preceding therapy with analgesics or NSAIDs, the effect of which was absent or insignificant. Patients were divided into 2 groups: I group (n = 52) received ketorol, II group (n = 43) - ketoprofen. The duration of therapy was 5 days. A comparative assessment of the intensity of pain according to your (0–100) against the background of taking drugs: before treatment, after 15, 30 minutes, 2, 6 hours. During the study, a change in the intensity of pain against the background of ketorol intake was obtained - 83.8 ± 11, 6 points (before treatment) VS 39.8 ± 20.8 points (after 6 hours), ketoprofen - 81.0 ± 10.8 points (before treatment) VS 46.7 ± 14.0 points (after 6 hours). Over the next 5 days, the regression of the pain syndrome was noted, and when using ketorol, a positive effect is achieved with a dynamically decreasing daily dose of the drug substance. When taking ketorol in 7.5% of cases, undesirable side effects were noted: discomfort and pain in the epigastric region, dizziness, difficulty in urination. Thus, the clinical efficiency and safety of ketorol in a dosage of 30 mg/day were demonstrated in the treatment of patients with acute pain for 5 days, which allows us to recommend this drug for wide use in outpatiental-linenic practice in patients with acute pain syndrome [19] . In the study by A.L. Vertkina et al. (2004) Assessment of comparative painkillers and safety of ketorolac and metamizole sodium in pain at the prehospital stage [20]. The study included 445 patients (the average age - 51 ± 4.9 years), which were divided into 2 groups: Ketorolak group (n = 220) and a group of sodium metamizole (n = 225). The severity of the pain syndrome is estimated by your (0–100), and patients also noted the level of pain intensity in 20 minutes. After a single in/m introduction of ketorolac at a dose of 30 mg. In the course of the study, the following results were obtained: 1) the analgesic efficiency of ketorolac (according to yours) is 2.6 times higher than that of the sodium metamizole; 2) the pain completely disappeared in 12.7% of cases after taking ketorolac and only in 2% after taking sodium metamizole; 3) the introduction of ketorolak was effective in all cases, in the group of metamizole sodium in 5.3% there was no effect. The frequency of development of side effects (most often dyspeptic symptoms) when using ketorolac was 2.7%. Thus, ketorolac provides high efficiency, rapid and prolonged anesthesia, and low risk of side effects. Not being an accounting drug, ketorolax can be recommended for use as an analgesic of the first row at the prehospital stage in an ambulance [20]. A.L. Vertkin et al. (2006), as part of the program of the National Scientific and Practical Society for the Emergency Medical Assistance, the first comparative open multicenter controlled clinical study of the efficiency and safety of the parenteral use at the pre-capital stage of NSAIDs (sodium, sodium diclofenac, ketorolac and loroxicam) was carried out with various origin of various origin [7 , 8]. The study included 1011 patients (average age - 54.1 ± 0.46 years). At the prehospital stage, they introduced a 2 ml of a 50% solution of in/m of metamizol sodium (n = 240), 3 ml - 75 mg of V/m of diclofenac (n = 153), or 30 mg/1 ml in/m ketorolac (n = 318 ), or 8 mg/2 ml in/m loroxicam (n = 95). From the study, 54.7% took part in urgent help in connection with skeletal-muscular pain, 24.1% for injury, 21.2% with renal colic. According to the criteria, your better efficiency was possessed by Loroxics and ketorolac, according to the results of the assessment of the dynamics of pain, ketorolalacts surpasses sodium metamizol by 1.3 times. In the course of the study, it was revealed: 1) by the number of repeated calls, the drugs are located as follows: metamizole> diclofenac> ketorolala = Loroxes; 2. min.; 3) according to the speed of the onset of a distinct painkillers, the drugs were distributed as follows: Loroxics = Ketorolak> Diclofenac> Metamizole; 4) by the strength of analgesic effect on injury, the studied drugs can be arranged as follows: ketorolala> Loroxics> Diclofenac = metamizole. The average difference in the intensity of the pain that occurred in connection with the injury before and after treatment for yours in the Metamizole group was 58.9 ± 3.0 points, diclofenac - 60.0 ± 4.6 points, ketorolac - 77.8 ± 1.9 score, loroxicam - 68.0 ± 4.7 points. According to this indicator, Ketorolakus was superior in analgesic activity to the Loroxes and the rest of the analgesics. Among the unwanted phenomena when using ketorolac in 9.4% of cases, dyspepsia was noted, in 2.9% - urticaria. Thus, the presented results indicate the feasibility of using ketorolac at the prehospital stage of the treatment of acute pain, while this drug is the most effective in injury and acute skeletal-muscle pain in comparison with other analgesics and NSAIDs [7, 8]. A.L. Vertkin et al. (2011) Assessment of the effectiveness and safety of the use of NSAIDs to stop the pain syndrome in the practice of the doctor on duty in a multidisciplinary hospital [21]. The study included 627 patients (average age - 56.7 ± 6.3 years) with pain syndrome, which were in a stationary treatment in a multidisciplinary hospital (compartment of therapy, general surgery, neurology) of ambulance). A metamizole of sodium + pythofenon + Fenpianius bromide at a dose of 5.0 ml iv, diclofenac - 75 mg iv, ketorolax - 10 mg iv, paracetamol - 500 mg iv droppings was prescribed. In assessing the effectiveness of reducing ketorolac pain, it turned out to be the most effective in patients in therapeutic departments, surgical practice. Assessing the analgesic potential of drugs in all departments, the authors note the greatest effectiveness of ketorolac. The most rapidly anesthetic effect was felt by the patients who were prescribed by ketorolac (48.7 minutes). After 12 hours, patients evaluated the quality of anesthesia on a 5-point scale and O-the average score 4.6. Thus, it is concluded that by the subjective assessment of the effectiveness of pain relief in your best drug for emergency anesthesia, ketorolac is. In terms of efficiency/safety ratio, the advantage in choosing pain relief in the practice of the doctor on duty of a multidisciplinary hospital also in ketorolac. In addition, the adequate relief of the painful syndrome is an important additional factor in the stabilization of blood pressure in patients with a hypertensive crisis [21]. The use of ketorolac in the treatment of cervicogenic headaches Effective therapy of cervicogenic headaches (CGB) is possible with a complex approach and joint use of pharmacological and non -drug methods, including blockades with local anesthetics. Medical blockades with local anesthetics temporarily reduce the intensity of pain and reliably increase the effect of drug therapy. In the treatment of CGB, drugs of various groups are used: NSAIDs, muscle relaxants, antidepressants, anticonvulsants [22]. At the same time, according to most experts, it is more preferable to use NSAIDs (ketorolak, diclofenac, nimesulide). The use of NSAIDs is possible both for stopping acute pain and as part of complex therapy for chronic CGB. It is advisable to prescribe drugs with a pronounced anti -inflammatory and analgesic effect, given the accompanying somatic pathology. In neurological practice, the use of Ketorolak is recommended in the treatment of the Central City Hospital for no more than 5 days in the form of in/m injections at a dose of up to 90 mg/day or in a tablet form of 20–40 mg/day [22]. The conclusion of the studies demonstrated the clinical efficiency and safety of the drug ketorolac in the form of in/m injections at a dose of up to 90 mg/day or in a tablet form of 20–40 mg/day (an average of 30 mg/day) for no more than 5 days in treatment Patients with acute pain syndrome [23]. According to the instructions for the new form of use of the drug, Ketorol Gel is applied 3-4 r/day (no more), the duration of use is up to 10 days [4]. The analgesic activity of Ketorolak exceeds such analgesics. The safety of the drug is confirmed on the basis of laboratory tests. Thus, the need for the widespread use of ketorolac (ketorola) in outpatient and voglinical practice is shown in patients with acute pain, at the prehospital stage in an ambulance as an analgesic of the first row, in the provision of ambulance, in the provision of ambulance with urgent conditions.

Literature 1. Alekseev V.V. Stepped NSAID therapy for acute pain in the lumbosacral region // Effective pharmacotherapy in neurology and psychiatry. 2010. No. 4. pp. 22–28. 2. Erokhin A.I., Voronkova V.V., Kuzin A.V. The effectiveness of Ketorol for pain syndrome at an outpatient dental appointment. URL: https://www.ketorol.ru. 3. Ketorolac: instructions for use. URL: https://www.rlsnet.ru/tn_index_id_1720.htm. 4. Ketorol: instructions for use. URL: https://www.ketorol.ru. 5. Shostak N.A., Pravdyuk N.G., Egorova V.A. Back pain in the elderly - approaches to diagnosis and treatment // Clinician. 2011. No. 3. pp. 72–77. 6. Timofeev A.A., Ushko N.A., Dakal A.V. and others. Comparative characteristics of non-narcotic analgesics used in maxillofacial surgery // Practitioner dentist. 2012. No. 2. P. 48–51. 7. Vertkin A.L., Topolyansky A.V., Vovk E.I. and others. The place of Ketorolac in the treatment of acute pain syndromes at the prehospital stage // Emergency Doctor. 2006. No. 6. P. 1–6. 8. Vertkin A.L., Topolyansky A.V., Vovk E.I. and others. The place of Ketorolac in the treatment of acute pain syndromes at the prehospital stage // Consilium medicum. 2006. T. 8. No. 2. P. 86–90. 9. Jelinek GA Ketorolac versus morphine for severe pain. Ketorolac is more effective, cheaper, and has fewer side effects // Br Med J. 2000. Vol. 321. R. 1236–1237. 10. Forrest JB, Camu F, Greer IA et al. Ketorolac, diclofenac, and ketoprofen are equally safe for pain relief after major surgery // Br J Anaesth. 2002. Vol. 88(2). R. 227–233. 11. Wood VM, Christenson JM, Innes GD et al. The NARC (nonsteroidal anti-inflammatory in renal colic) trial. Single-dose intravenous ketorolac versus titrated intravenous meperidine in acute renal colic: a randomized clinical trial // CJEM. 2000. Vol. 2 (2). R. 83–89. 12. Moeller C., Pawlowski J., Pappas AL et al. The safety and efficacy of intravenous ketorolac in patients undergoing primary endoscopic sinus surgery: a randomized, double-blinded clinical trial // Int Forum Allergy Rhinol. 2012. Vol. 2 (4). R. 342–347. 13. Mireku-Boateng AO Intravenous ketorolac significantly reduces the pain of office transrectal ultrasound and prostate biopsies // Urol Int. 2004. Vol. 73(2). R. 123–124. 14. Bazikyan E.A., Ignatovich V.V. Evaluation of the effectiveness of Ketorol and Nise in the clinical practice of surgical dentistry // Dentistry. 2005. T. 84. No. 3. P. 49–50. 15. Egorova O.A. Efficacy and safety of Ketorol for pain syndrome in an outpatient surgical dentistry clinic // Dentistry. 2009. No. 6. pp. 53–54. 16. Galushko E.A., Zotkin E.G., Salikhov I.G. and others. Clinical effectiveness and tolerability of various NSAIDs for osteoarthritis with severe pain // Attending physician. 2008. No. 4. pp. 82–84. 17. Garkavi A., Silin L., Semevsky A. Relief of acute pain syndrome in patients with pathology of the musculoskeletal system in the early post-traumatic and postoperative periods // Doctor. 2006. No. 13. pp. 40–44. 18. Skvortsov V.V., Tumarenko A.V., Odintsov V.V. and others. Current issues in the diagnosis and treatment of glenohumeral periarthritis // Polyclinic. 2011. No. 2. P. 56–58. 19. Bragina G.I., Vinogradova L.A., Gorshkova Yu.M. and others. Pain syndrome in outpatient practice: Ketorol // Bulletin of Family Medicine. 2006. No. 2. P. 44–47. 20. Vertkin A.L., Prokhorovich E.A., Goruleva E.A. and others. Efficacy and safety of using Ketorol for pain relief at the prehospital stage // Emergency Therapy. 2004. No. 1–2. pp. 16–17. 21. Vertkin A.L., Shamuilova M.M., Naumov A.V. Assessing the effectiveness and safety of the use of non-steroidal anti-inflammatory drugs for pain relief in the practice of an on-duty doctor in a multidisciplinary hospital // Drug supply and pharmacoeconomics. 2011. No. 5. pp. 76–84. 22. Tabeeva G.R. Cervicogenic headache: pathophysiology, clinical picture, approaches to therapy // Neurology, neuropsychiatry, psychosomatics. 2010. No. 2. pp. 19–26. 23. Shavlovskaya O.A. Clinical efficacy and tolerability of Ketorolac in the treatment of pain syndromes // Consilium medicum. 2013. T. 15. No. 2. P. 34–37.

Side effects

More than 3% of patients with parenteral administration and oral administration of Ketorol experience:

• diarrhea and gastralgia (especially in older people with a history of peptic ulcer disease);
• dizziness , increased drowsiness , headache ;
• swelling (fingers, feet, ankles, legs, face);
• weight gain.

Somewhat less frequently (in 1-3% of patients) the following were recorded:

• flatulence , stomatitis , feeling of fullness in the stomach, vomiting, constipation ;
• increased blood pressure ;
• purpura, rash (including maculopapular) on the skin;
• pain and/or burning sensation at the injection site;
• increased sweating .

Rare side effects that occur in less than 1% of patients:

• nausea;
• formation of erosions on the gastrointestinal mucosa or its ulceration (including with perforation and/or bleeding, the symptoms of which are burning, pain and spasm in the epigastric region, bloody vomiting (coffee grounds), melena, heartburn , nausea, etc.);
• hepatomegaly;
• hepatitis;
• acute inflammation of the pancreas;
• surge arrester;
• cholestatic jaundice;
• lower back pain (sometimes accompanied by azotemia and/or hematuria );
• renal failure dominating the clinical picture , as well as hemolytic anemia and thrombocytopenia ;
• change in urine volume (decrease or increase);
• frequent urination;
• edema of renal origin;
• nephritis;
• hearing loss, tinnitus ;
• visual impairment (blurred perception of visual images);
• rhinitis , bronchospasm , laryngeal edema;
• aseptic meningitis;
• hyperactivity (restlessness, mood swings);
• depression;
• mental disorders;
• hallucinations;
• sudden loss of consciousness;
• edema ;
• swelling of the tongue;
• leukopenia , eosinophilia , anemia ;
• bleeding (from the lower gastrointestinal tract, nose, postoperative wound);
• exfoliative dermatitis;
• Lyell's syndrome , malignant exudative erythema , urticaria ;
• anaphylactoid reactions or anaphylaxis ;
• fever.

When ketorolac , peeling of the skin at the site of application of the gel, urticaria , and itching .

When applying the drug to a large area of ​​the body, the possibility of developing systemic effects cannot be excluded, including:

• ulceration of the mucous membrane of the digestive canal;
• heartburn , diarrhea , vomiting, nausea, gastralgia ;
• increased activity of liver aspartate and alanine aminotransferase;
• dizziness , headache ;
• hematuria;
• fluid retention;
• hypersensitivity reactions;
• prolongation of bleeding time;
• anemia , leuko- and thrombocytopenia , agranulocytosis .

Instructions for use of Ketorol

Ketorol tablets: instructions for use

The medicine is taken orally from 1 to 4 times a day. A single dose is one tablet. The highest daily dose is four tablets. Treatment should last no more than 5 days in a row.

When switching from parenteral administration to the tablet form of the drug, the total dose of the drug in the form of tablets and solution on the day of transfer should not exceed 90 mg/day if the patient is under 65 years of age, and 60 mg/day if the patient is older than the specified age.

The upper limit of the daily dose of Ketorol in tablets on the day of transition is 30 mg.

Ketorol injections: instructions for use

The solution is intended for intramuscular and intravenous administration. The drug in this dosage form must be used in minimally effective doses.

If necessary, Ketorol can be used in combination with narcotic analgesics (the latter are prescribed in reduced doses).

For patients under 65 years of age, provided that their weight is more than 50 kg, no more than 2 ml of solution can be injected into the muscle once (including oral administration). As a rule, to relieve pain, 1 ml of Ketorol is administered in ampoules every six hours.

Ketorol is administered intravenously in 1 ml doses so that the volume of medication administered over five days does not exceed 15 single doses.

For patients weighing less than 50 kg, as well as patients with chronic renal failure, a single dose when administering Ketorol into the muscle should not exceed 1 ml of solution (including oral administration).

As a rule, the drug is administered in 0.5 ml doses so that the patient receives no more than 20 single doses in five days.

No more than 0.5 ml of solution can be administered intravenously to a patient with chronic renal failure or weighing less than 50 kg every six hours (within five days, no more than 20 single doses).

The upper limit of the daily dose for parenteral administration of Ketorol for patients under 65 years of age weighing more than 50 kg is 90 mg, for patients with chronic renal failure and patients weighing less than 50 kg is 60 mg.

The drug can be used for no more than 5 days in a row.

The IV solution should be administered over at least 15 seconds. Ketorol is injected intramuscularly deep into the muscle and also slowly.

The drug begins to act half an hour after administration. Maximum pain relief is observed an hour or two after the injection.

Ketorol Gel: instructions for use

The gel (ointment) should be applied to washed and dried skin. A single dose of the medicine is a column 1-2 cm long. Ketorol is distributed on the surface of the most painful area with soft massaging movements 3-4 times a day.

Re-use of the drug is possible no earlier than after 4 hours.

The gel can be used no more than 4 times a day. Do not exceed the recommended dose.

If after 10 days of treatment with Ketorol the patient’s condition does not improve or the pain and inflammation intensify, it is necessary to stop using the drug and seek medical help.

Without consulting a doctor, the gel can be used for no more than 10 days.

Additionally

If the drug is used in combination with narcotic analgesics (solution, tablets or suppositories), the dose of the latter may be reduced.

Use of ketorolac among postoperative patients

When considering pain management in postoperative patients, ketorolac was in some cases more effective than morphine and meperedine [9], and side effects such as nausea and vomiting were less common with its use. When compared with other NSAIDs, ketorolac demonstrated a more pronounced analgesic effect for postoperative patients. Thus, according to one study, the use of ketorolac (30 mg intravenously) in postoperative patients reduced the need for additional prescription of narcotic analgesics more than the use of diclofenac or ketoprofen [10]. According to another study, a single injection of 30 mg of ketorolac or 75 mg of diclofenac did not provide sufficient analgesia in women undergoing laparoscopic sterilization, but in 60% of cases, repeated injection of the analgesic reduced pain [11]. Tolerability of both drugs was quite good, but pain at the injection site of ketorolac persisted for 15–30 minutes, and at the injection site of diclofenac for 8–12 hours. A study by J. Forrest et al., which included 11,245 patients who underwent surgery, showed that ketorolac therapy in the postoperative period is as safe as treatment with diclofenac or ketoprofen. With a single intravenous administration, side effects turned out to be mild and transient; possible drowsiness, pain at the injection site, increased sweating, nausea, headache, etc. [12].

In order to study the analgesic effect of ketorolac in comparison with placebo and opiates, which were used to relieve pain in postoperative patients, an analysis was conducted of journal articles published in English in 1986-2001 and the results of randomized controlled trials. At the same time, the frequency of side effects and the quality of pain relief when using ketorolac were assessed. The following data were obtained: when using ketorolac, the dose of opioid analgesics was reduced by an average of 36% (range from 0 to 73%). Better pain relief was achieved among patients who used ketorolac in combination with opiates. The risk of side effects from ketorolac increased with high doses, with treatment durations exceeding 5 days, or in patients at risk (for example, the elderly) [13].

In an analysis of 13 randomized controlled trials that assessed the analgesic effect of single doses of ketorolac and opioids in postoperative patients, the effects of different doses of ketorolac (30 and 60 mg) were examined. The following conclusions were drawn: a single dose of ketorolac is an effective adjunct in reducing postoperative pain and postoperative nausea and vomiting. There were no significant differences in the analgesic effect obtained when using 30 and 60 mg of ketorolac [14].

Overdose

Symptoms of overdose for parenteral use and oral administration: nausea, abdominal pain, vomiting, renal dysfunction, erosive lesions and ulceration of the gastrointestinal mucosa, metabolic acidosis .

If signs of intoxication , the victim is given gastric lavage and enterosorbents . Further treatment is symptomatic. ketorolac to be sufficiently removed from the body.

Cases of overdose with external use of the drug have not been described. If you accidentally ingest the gel, you should empty your stomach (induction of vomiting and taking an enterosorbent ) and consult a doctor.

Interaction

Drug interactions for Ketorol solution and tablets

The use of ketorolac in combination with other NSAIDs, ASA ( acetylsalicylic acid ), ethanol, calcium preparations, corticotropin and corticosteroids can lead to ulceration of the gastrointestinal mucosa and the development of bleeding from ulcerative defects.

Co-administration with Methotrexate increases hepato- and nephrotoxicity, and with Paracetamol - nephrotoxicity. With Methotrexate, ketorolac can be prescribed only if Methotrexate is used in the lowest possible dose (in this case, plasma concentrations of methotrexate ).

Probenecid reduces the volume of distribution and plasma clearance of ketorolac , increases its plasma concentration and increases the half-life. With the use of ketorolac, Methotrexate may decrease , and the toxicity of these substances may increase.

Use in combination with indirect anticoagulants and drugs for thrombolytic therapy , Heparin , cephalosporin antibiotics , antiplatelet agents increases the risk of bleeding.

Ketorolac , acting as an inhibitor of Pg synthesis in the kidneys, reduces the effect of diuretics and antihypertensive drugs .

In the case of simultaneous use with narcotic painkillers, the doses of the latter may be significantly lower.

Antacids do not alter the absorption of ketorolac .

Increases the hypoglycemic effect of oral antidiabetic agents and insulin , which requires dose recalculation.

Combined use with valproic acid provokes a violation of platelet aggregation.

Increases plasma concentrations of Nifedipine and Verapamil .

When combined with other nephrotoxic drugs (for example, with Au preparations), the likelihood of nephrotoxic effects increases.

Drugs that block tubular secretion reduce clearance and increase plasma concentrations of ketorolac .

Drug interactions with topical use of ketorolac

The possibility of pharmacokinetic interaction with drugs competing for binding to plasma proteins cannot be ruled out.

The gel should be used with caution in combination with Phenytoin , other NSAIDs, diuretics , Digoxin , Cyclosporine , Li drugs, Methotrexate , antidiabetic and antihypertensive drugs .

Patients using any of the listed drugs should begin treatment with Ketorol only with the approval of a physician.

special instructions

The choice in favor of one or another dosage form is made taking into account the indications for use and the intensity of pain.

Pills:

Use of Ketorol for more than five days in a row and/or at a dose exceeding the maximum allowable increases the risk of adverse reactions.

The drug should not be prescribed simultaneously with other NSAIDs, since simultaneous use with them leads to cardiac decompensation, fluid retention, and increased blood pressure .

The effects due to the effect of ketorolac on platelet disappear after 24–48 hours.

Ketorolac can change the properties of platelets, but the drug does not replace the preventive effect of ASA in pathologies of the heart and blood vessels.

To reduce the likelihood of developing NSAID gastropathy , the drug should be taken with Omeprazole , Misoprostol , and antacids .

Before prescribing the solution, you should find out whether the patient has previously had an allergic reaction to the drug or other NSAIDs. Due to the risk of hypersensitivity reactions, the first dose is administered under close medical supervision.

Hypovolemia increases the risk of nephrotoxic effects.

It is not recommended to use the solution as a means to prepare a patient for general anesthesia, as well as to maintain anesthesia during extensive surgical interventions.

During treatment with Ketorol, it is recommended to be careful when driving a car or using machinery.

gel (ointment) is recommended to be applied only to intact skin, avoiding contact with wounds and mucous membranes (including the eyes).

The drug should not be used under dressings made of airtight materials. After applying Ketorol to the skin, you should wash your hands well with soap.

Use of ketorolac in dentistry

Skeletal bones contain many prostaglandins (PGs), mainly PGE2, which model the functions of osteoblasts and osteoclasts under physiological and pathological conditions. The anabolic effect of PGE2 on bone tissue is observed mainly in response to mechanical stress and during repair processes [24]. Therefore, there is a potential risk of decreased bone tissue repair when using selective and non-selective NSAIDs. This is due to the fact that NSAIDs inhibit the action of cyclooxygenase (COX), and COX, in turn, catalyzes the conversion of arachidonic acid to PG [25]. Although NSAIDs are among the most commonly used drugs for the treatment of acute and chronic pain in clinical dentistry [26], very few studies have assessed their effects on alveolar tissue. Moreover, research data is contradictory: some researchers report the harmful effects of traditional NSAIDs on alveolar tissue [27], others do not find significant differences in the rate of tissue healing [28].

Some authors report that ketorolac can negatively affect bone tissue repair in various experimental models (healing of femur and ulna fractures in rats and rabbits) [29], others do not note the effect of ketorolac on the healing of tibia fractures in mice [30]. A study on rats that had a tooth removed and subsequently assessed the effect of bone tissue healing while taking ketorolac, etoricoxib or paracetamol showed that long-term treatment (2 weeks) with these drugs did not have a negative effect on alveolar bone healing, which was confirmed by histometric methods [31].

Ketorol's analogs

Level 4 ATC code matches:
Voltaren Emulgel

Ultrafastin

Indomethacin

Dicloran

Dicloran Plus

Dolgit

Nise

Ketonal

Febrofeed

Fastum gel

Diclofenac

Finalgel

Bystrumgel

Deep Relief

Butadion

Diklovit

Artrosilene

Olfen

Fanigan Fast

Structural analogues of tablets and solution: Adolor , Vatorlak , Ketanov , Dolak , Dolomin , Ketofril , Ketalgin , Ketorolac , Ketocam .

Drugs with a similar mechanism of action: Arthrotek , Bioran , Voltaren , Diclak , Diclogen , Diclofenac , Indomethacin , Naklofen , Ortofen , Neurodiclovit , Flotac , SwissJet .

Suppositories with a similar effect: Voltaren , Diclak , Diclonate P , Naklofen , Diclofenac , Indomethacin .

What is better - Ketorol or Ketonal?

Ketonal is a drug based on the NSAID ketoprofen (a derivative of propionic acid). The medicine has the same indications for use as Ketorol.

When administered parenterally, the analgesic effect appears within 15-30 minutes. With intravenous infusion of ketorolac , plasma concentrations reach maximum values ​​after 4 minutes.

The difference between ketoprofen and ketorolac is also a shorter half-life - less than 2 hours.

Studies of the effectiveness of drugs for pain relief in postoperative patients have shown that ketorolac provides a faster, more effective and longer-lasting effect than its analogue, and also has a lesser effect on the hemostatic system.

Safety of using ketorolac

The results, obtained from an analysis of post-marketing surveillance of more than 20 thousand patients, showed that the overall risk of developing gastrointestinal complications or bleeding associated with parenteral ketorolac therapy was only slightly higher than with the use of opiates. However, this risk increased markedly when high doses were used for more than 5 days, especially in the elderly.

Another side effect is acute renal failure, which can also occur during treatment with ketorolac, and is usually reversible and regresses after discontinuation of the drug [8]. Indeed, the literature describes cases of the development of acute renal failure after injection of ketorolac [32, 33], including a single one [33]. According to other data, no nephrotoxic effect of ketorolac was detected on healthy individuals who underwent donor nephrectomy [34]. In a multicenter study that included more than 20 thousand patients, the incidence of acute renal failure was 1.1% during ketorolac therapy. It has been shown that the risk of developing renal failure is low with a duration of treatment with ketorolac of less than 5 days, but increases with longer use [35]. A meta-analysis of the effects of NSAIDs (including ketorolac) on the renal function of postoperative patients showed a statistically significant, but clinically unexpressed, transient impairment of renal function.

As a result, the authors concluded that patients with normal renal function should not avoid NSAIDs for fear of postoperative renal dysfunction [36]. Other unwanted effects of ketorolac may be related to its effect on blood clotting. According to some authors, intravenous administration of ketoprofen or ketorolac, or diclofenac causes reversible platelet dysfunction, however, during therapy with ketorolac this effect lasted the longest (within 24 hours after injection). Other authors do not identify an increase in the risk of hematoma formation after major surgery associated with the use of ketorolac [37, 38]. According to a study conducted by García Rodríguez, the risk of gastric bleeding with ketorolac is higher than with other NSAIDs [39]. Patients receiving ketorolac had a 5-fold greater risk of bleeding than those not receiving this treatment; when using other NSAIDs, the risk of bleeding increased 4.4 times. This led the authors to warn practitioners against routine use of ketorolac.

In addition, the risk of postoperative bleeding associated with the use of ketorolac was examined. An increased risk of postoperative wound bleeding and gastric bleeding was found; the risk increased with increasing drug dose and treatment duration beyond 5 days. Thus, in order to avoid the development of serious complications, ketorolac, according to many authors, should be used in the lowest dose that allows pain control and for as short a period as possible [40].

Is it possible to give Ketorol to children?

The annotation states that all dosage forms of the drug are intended for the treatment of patients over 16 years of age (according to Wikipedia, age under 16 years of age is a relative contraindication).

The reason for this restriction is that the use of ketorolac in children can cause visual and hearing impairment, depression , nephritis , pulmonary edema , allergic reactions and other severe complications.

Therefore, it is better to give the child safer means to relieve pain - for example, paracetamol or ibuprofen .

Reviews of Ketorol

Reviews of Ketorol tablets, as well as reviews of injections and gel, are positive in 95-98% of cases. Ketorol helps with toothache, back and muscle pain, and headaches within half an hour, and its effect lasts up to six hours.

Most patients note that when using the medicine in accordance with the instructions, side effects occur extremely rarely. Sometimes the disadvantages of Ketorol are a large number of contraindications and the impossibility of long-term use.

Use of ketorolac for injury and back pain

Ketorolac can be considered a drug of choice for the relief of intense pain, especially in case of injury, however, its short-term use is also possible during exacerbation of chronic pain in patients with degenerative diseases of the spine, rheumatoid arthritis, osteoarthritis, etc. According to a double-blind prospective study, among patients with severe back pain, the effectiveness of ketorolac was comparable to the effects of meperedine, and the sedation and side effects were less pronounced [15]. A multicenter clinical trial evaluated the analgesic effects of ketorolac for back pain and found it to be comparable to those of codeine with significantly fewer adverse events [16].

A clinical trial of 148 patients hospitalized for closed limb injuries received intravenous ketorolac (30 mg) or morphine (15 mg). With complete immobility of the affected limb, ketorolac and morphine had a similar analgesic effect, and with small movements of the affected limb associated with the manipulations, the effectiveness of ketorolac was even higher. The incidence of side effects when using ketorolac was 16 times lower than when using morphine, which more often caused nausea, vomiting, and phlebitis. The authors concluded that patients receiving ketorolac required less attention from nursing and physician staff [17].

How much do Ketorol tablets, gel and ampoules cost?

The price of Ketorol in tablets in Ukrainian pharmacies is 29-37 UAH. Injections can be bought for 98-105 UAH. The price of Ketorol gel is 55-62 UAH.

In Russia, the average price of Ketorol in tablets is 45 rubles, the price of Ketorol in ampoules is 145 rubles, the cost of ointment (gel) is 215 rubles.

• Online pharmacies in RussiaRussia
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• Online pharmacies in KazakhstanKazakhstan

ZdravCity

• Ketorolac Welfarm solution for IV and IM injection 30 mg/ml amp.
  1ml 10 pcs. Welfarm LLC 62 rub. order
• Ketorol solution for intravenous and intramuscular administration. 30mg/ml 1ml 10 pcs.Dr. Reddy's lab.

  134 RUR order

• Ketorol gel 2% 30gDr. Reddy's lab.

  RUB 291 order

• Ketorol express tab. dispersant in the oral cavity 10 mg 20 pcs.Dr. Reddy's lab.

  65 rub. order

• Ketorolac tab. p.p.o. 10mg 20pcs JSC Tatkhimfarmpreparaty

  35 rub. order

Pharmacy Dialogue

• Ketorolac (amp. 30 mg/ml 1 ml No. 10) Sintez (Kurgan) OJSC

  81 RUR order

• Ketorol (gel tube 2% 50g)Dr. Reddy's

  RUB 413 order

• Ketorol Express (tablet dispensed in half the mouth 10 mg No. 20) Dr. Reddy's Laboratories Ltd.

  67 RUR order

• Ketorolac (amp. 30 mg/ml 1 ml 2x5 No. 10) Ellara LLC

  51 RUR order

• Ketorolac (amp. 30 mg/ml 1 ml No. 10) Welfarm LLC

  57 RUR order

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Pharmacy24

• Ketorol 2% 30 g gel Dr. Reddy's Laboratories Ltd., India
  72 UAH.order
• Ketorol 30 mg/1 ml N10 solution Dr. Reddy's Laboratories Ltd., India

  175 UAH order

• Ketorol 10 mg No. 20 tablets Dr. Reddy's Laboratories Ltd., India

  75 UAH order

PaniPharmacy

• Ketorol tablets Ketorol film-coated tablets 10 mg No. 20 India, Dr. Reddy's

  93 UAH order

• KETOROLAC ampoule Ketorolac r/r d/in. 3% 1ml. No. 10 Ukraine, Health LLC

  99 UAH order

• Ketorol ampoule Ketorol solution d/in. 30mg amp. 1ml No. 10 India, Dr. Reddy's

  152 UAH order

• KETOROLAC tablets Ketorolac tablets. 10mg No. 10 Ukraine, Health LLC

  18 UAH order

• Ketorol gel Ketorol gel 2% 30g India, Dr. Reddy's

  85 UAH order

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