Compared to higher doses, 10mg of intravenous (IV) ketorolac (analgesic ceiling dose) provided effective pain relief without increased adverse effects in emergency department (ED) patients with moderate to severe pain, according to a study published in the Annals of Emergency Medicine.

Ketorolac tromethamine, a nonsteroidal anti-inflammatory drug (NSAID), is one of the most commonly used parenteral analgesics in the ED.NSAIDs are frequently dosed above their analgesic ceiling; this often provides no additional analgesic benefit but may potentially increase the risk of harm. Study authors aimed to evaluate the effectiveness of three doses of IV ketorolac in the ED among patients with acute pain. 

A randomized, double-blind trial (n=240) was conducted to assess IV ketorolac 10mg, 15mg, and 30mg in patients aged 18–65 years old presenting with moderate to severe to acute pain. Patients with peptic ulcer disease, gastrointestinal hemorrhage, renal or hepatic impairment, NSAID allergies, pregnancy or breastfeeding, systolic blood pressure <90mmHg or >180mmHg, and pulse rate <50bpm or >150bpm were excluded. 

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The primary outcome was pain reduction at 30 minutes. Study authors recorded pain scores at baseline and up to 120 minutes. If patients still needed additional pain relief at 30 minutes after the study drug was administered, IV morphine 0.1mg/kg was given as a rescue analgesic. 

At 30 minutes, substantial pain reduction was seen without any differences between the groups (10mg: 95% CI: 4.5–5.7; 15mg: 95% CI: 4.5–5.6; 30mg: 95% CI: 4.2–5.4). The mean numeric rating scale pain scores at baseline were 7.7 for the 10mg dose, 7.5 for the 15mg dose, and 7.8 for the 30mg dose, which improved to 5.1, 5.0, and 4.8, respectively at 30 minutes. The use of rescue morphine was similar between the treatment arms, and no serious adverse events were reported. 

The study’s secondary outcomes showed similar rates of adverse effects for each group; the most commonly reported were dizziness, nausea, and headache.

Overall, IV ketorolac demonstrated similar analgesic effects at doses of 10mg, 15mg, and 30mg. “The results of our study provide a basis for changes in practice patterns and guidelines in ED care, supporting use of the 10-mg intravenous ketorolac dose,” concluded the authors.

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