Ketorolac. A review of its pharmacodynamic and pharmacokinetic properties, and therapeutic potential

Optimizing pain management and pupil dilation in cataract surgery: a systematic review and meta-analysis of phenylephrine/ketorolac (OMIDRIA®)

PURPOSE

This systematic review and meta-analysis aims to evaluate the efficacy and safety of the combination of phenylephrine 1% and ketorolac 0.3% (OMIDRIA®) for optimizing pain management and maintaining pupil dilation during cataract surgery. Comparisons were made against placebo/vehicle, phenylephrine alone, and epinephrine.

METHODS

A comprehensive search of PubMed, Cochrane CENTRAL, Embase, Scopus, and Web of Science was conducted. Eligible studies were randomized clinical trials and observational studies assessing intracameral phenylephrine/ketorolac against control groups. Key outcomes included pain management, pupil diameter, and adverse events. Data were synthesized using meta-analysis with fixed and random-effects models, and heterogeneity was assessed using the I2 statistic.

RESULTS

Ten studies, including 220,061 patients, were analyzed. The combination of phenylephrine/ketorolac significantly reduced postoperative pain (RR = 0.72, 95% CI: 0.60-0.86) and opioid use (RR = 0.45, 95% CI: 0.23-0.89) compared to vehicle and epinephrine. PE/K also maintained a larger pupil diameter (MD = 0.54 mm, 95% CI: 0.32-0.75) with minimal heterogeneity (I2 = 0%) and reduced the incidence of severe pain (RR = 0.41, 95% CI: 0.27-0.63). No significant differences in adverse events such as elevated intraocular pressure, inflammation, or headaches were observed.

CONCLUSION

Phenylephrine/ketorolac (OMIDRIA®) demonstrates superior efficacy in maintaining intraoperative mydriasis, reducing postoperative pain, and minimizing opioid use without increasing adverse events. This combination offers a preferable alternative to traditional agents, potentially setting a new standard for pain management and pupil dilation in cataract surgery.

Anaphylactic shock induced by intravenous ketorolac: A case report

Ketorolac trometamol injection is the first injectable nonsteroidal anti-inflammatory drug (NSAID) approved for the short-term management of moderate to severe pain. As a non-opioid alternative, it represents a critical development for acute pain relief, particularly in postoperative and injury-related scenarios. Like other NSAIDs, ketorolac trometamol is associated with common adverse reactions such as dizziness, headache, drowsiness, nausea, and vomiting, which are generally mild to moderate. However, rare but severe reactions like anaphylactic shock have been reported. This case report highlights a specific instance of anaphylactic shock induced by intravenous ketorolac trometamol, emphasizing the rapid onset of symptoms and the importance of vigilant monitoring during administration to prevent severe outcomes. Additionally, recommendations for post-recovery monitoring and allergological evaluation are provided to enhance clinical management in similar cases.

Current research status, applications and challenges of ketorolac-based sustained-release and controlled-release formulations

Ketorolac, a nonsteroidal anti-inflammatory drug, exhibits moderate antipyretic and anti-inflammatory properties, as well as potent analgesic effects. It is widely used in clinical practice for pain relief in cases of mild and severe pain such as postoperative pain, fractures, sprains, toothaches and cancer pain. Due to its relatively short half-life, patients experiencing pain often need frequent injections or oral medications, leading to poor patient compliance. Thus, it is crucial to create long-acting sustained-release formulations of ketorolac. This paper provides an overview of the research, applications, and challenges associated with ketorolac sustained-release formulations over the past decade, based on a comprehensive review of the literature. The aim is to provide fresh insights for the research and development of long-acting, sustained-release, and controlled-release formulations of ketorolac.

Characterization of HPMC and PEG 400 Mucoadhesive Film Loaded with Retinyl Palmitate and Ketorolac for Intravaginal Administration

Intravaginal drug administration offers several advantages over other routes, primarily bypassing the initial stages of metabolism. Additionally, this route has demonstrated both local and systemic effects. Mucoadhesive polymeric systems can be utilized to prevent dose loss due to the mucous barriers and the formation of wet cavities. This study employed various techniques to evaluate the performance and characteristics of a mucoadhesive film composed of HPMC-PEG 400 containing retinyl palmitate and ketorolac molecules. Scanning Electron Microscopy (SEM) was employed to analyze the porous structure of the film. Thermogravimetric Analysis (TGA) was conducted at different temperatures to assess thermal stability. Fourier Transform Infrared Spectroscopy (FTIR) was used to analyze the functional groups and intermolecular interactions between the film and the drug. Swelling and weight loss tests indicated that the film disintegrated within 3-4 days. UV-VIS spectroscopy was used for drug release evaluation based on the Higuchi equation. Additionally, the surface wetting properties were assessed through contact angle measurements. The system's biocompatibility was confirmed using the MTT assay. Finally, adhesion and glide tests demonstrated the film's interaction with porcine uterine tissue. This study shows that the HPMC-PEG 400 film containing retinyl palmitate molecules interacts effectively with tissue and could be considered a novel tool for treating damaged epithelial tissues.

Revisiting and Updating the Interaction between Human Serum Albumin and the Non-Steroidal Anti-Inflammatory Drugs Ketoprofen and Ketorolac

Ketoprofen (KTF) and ketorolac (KTL) are among the most primarily used non-steroidal anti-inflammatory drugs (NSAIDs) in humans to alleviate moderate pain and to treat inflammation. Their binding affinity with albumin (the main globular protein responsible for the biodistribution of drugs in the bloodstream) was previously determined by spectroscopy without considering some conventional pitfalls. Thus, the present work updates the biophysical characterization of the interactions of HSA:KTF and HSA:KTL by 1H saturation-transfer difference nuclear magnetic resonance (1H STD-NMR), ultraviolet (UV) absorption, circular dichroism (CD), steady-state, and time-resolved fluorescence spectroscopies combined with in silico calculations. The binding of HSA:NSAIDs is spontaneous, endothermic, and entropically driven, leading to a conformational rearrangement of HSA with a slight decrease in the α-helix content (7.1% to 7.6%). The predominance of the static quenching mechanism (ground-state association) was identified. Thus, both Stern-Volmer quenching constant (KSV) and binding constant (Kb) values enabled the determination of the binding affinity. In this sense, the KSV and Kb values were found in the order of 104 M-1 at human body temperature, indicating moderate binding affinity with differences in the range of 0.7- and 3.4-fold between KTF and KTL, which agree with the previously reported experimental pharmacokinetic profile. According to 1H STD-NMR data combined with in silico calculations, the aromatic groups in relation to the aliphatic moiety of the drugs interact preferentially with HSA into subdomain IIIA (site II) and are stabilized by interactions via hydrogen bonding and hydrophobic forces. In general, the data obtained in this study have been revised and updated in comparison to those previously reported by other authors who did not account for inner filter corrections, spectral backgrounds, or the identification of the primary mathematical approach for determining the binding affinity of HSA:KTF and HSA:KTL.

Resorbable nanofibrous membranes for local and sustained co-delivery of acyclovir and ketorolac in herpes therapy

Herpes simplex and herpes zoster are both viral infections caused by members of the herpesvirus family. The former is characterized by painful, fluid-filled blisters or sores on the skin and mucous membranes, while the latter presents as a painful rash with blisters, typically occurring in a single band or patch along one side of the body. The treatment remains a challenge since current antiviral therapy via oral administration may lead to unfavorable side effects such as headaches, nausea, and diarrhea. This study used electrospinning to develop biodegradable nanofibrous poly(lactic-co-glycolic acid) (PLGA) membranes for delivery of both acyclovir and ketorolac. The structure of the spun nanofibers was assessed via scanning electron microscopy (SEM), and the appearance of loaded acyclovir and ketorolac in the nanofibers was confirmed with Fourier-transform infrared spectroscopy (FTIR) and differential scanning calorimetry (DSC). Release profiles of these drugs from the nanofibrous membranes were assessed using in vitro elution studies, high-performance liquid chromatography (HPLC) assays, and in vivo drug release patterns. The electrospun nanofibers had a size range of 283-725 nm in diameter, resembling the extracellular matrix of natural tissue and demonstrated excellent flexibility and extensibility. Notably, the drug-eluting nanofibers exhibited an extended release of high levels of acyclovir and ketorolac over a 21-day period. Thus, biodegradable drug-eluting membranes with a prolonged drug release could be a potential therapeutic approach for treating herpes infections.

The Additive Antinociceptive Effect of Resveratrol and Ketorolac in the Formalin Test in Mice

Pain represents one of the leading causes of suffering and disability worldwide. Currently available drugs cannot treat all types of pain and may have adverse effects. Hence, the use of pharmacological combinations is an alternative treatment strategy. Therefore, this study aimed to evaluate the combination of resveratrol and ketorolac through isobolographic analysis. CD1 mice were used to study the antinociceptive effect of this combination using the formalin test and the study was divided into two phases. In the first phase, four individual doses of each drug were evaluated, totaling eight testing groups. From these data, the median effective doses (ED50) of each drug were calculated. In the second phase, four testing groups were used to evaluate the combination of sub-doses of both drugs and obtain the experimental ED50. To evaluate gastric damage, five groups were employed, including indomethacin, vehicle, resveratrol, ketorolac, and combined resveratrol and ketorolac groups. Stomach samples from the mice were taken after 5 h of treatment, and the area of the ulcers was determined. Resveratrol plus ketorolac elicited a reduction in nociceptive behavior during both phases of the formalin test, and isobologram analysis revealed that the theoretical and experimental ED50 values of resveratrol and ketorolac did not differ significantly, implying an additive interaction between the drugs. Additionally, the drug combination did not generate gastric ulcers, thus enhancing the desired effects without increasing the adverse effects. Consequently, these findings substantiate the efficacy of the resveratrol and ketorolac combination in the formalin test, thereby highlighting its potential as a viable alternative for alleviating pain.

Semi-IPN hydrogels of collagen and gum arabic with antibacterial capacity and controlled release of drugs for potential application in wound healing

The preparation of hydrogels based on biopolymers like collagen and gum arabic gives a chance to provide novel options that can be used in biomedical field. Through a polymeric semi-interpenetration technique, collagen-based polymeric matrices can be associated with gum arabic while controlling its physicochemical and biological properties. To create novel hydrogels with their potential use in the treatment of wounds, the semi-interpenetration process, altering the concentration (0-40% by wt) of gum arabic in a collagen matrix is explored. The ability of gum arabic to create intermolecular hydrogen bonds in the collagen matrix enables the development of semi-interpenetrating polymeric networks (semi-IPN)-based hydrogels with a faster gelation time and higher crosslinking. Amorphous granular surfaces with linked porosity are present in matrices with 30% (by wt) of gum arabic, enhancing the storage modulus and thermal degradation resistance. The hydrogels swell to very high extent in hydrolytic and proteolytic environments, good hemocompatibility, and suppression of growth of pathogens like E. coli, and all it is enhanced by gum arabic included them, in addition to enabling the controlled release of ketorolac. The chemical composition of theses semi-IPN matrices have no deleterious effects on monocytes or fibroblasts, promoting their proliferation, and lowering alpha tumor necrosis factor (α-TNF) secretion in human monocytes.

A Critical Review on the Pharmacodynamics and Pharmacokinetics of Non-steroidal Anti-inflammatory Drugs and Opioid Drugs Used in Reptiles

Non-steroidal anti-inflammatory drugs (NSAIDs) and opioids are analgesics used for moderate to severe pain in many animals, including reptiles. However, reptilian dosing regimens are often extrapolated from other animal species. This is not ideal as inter- and intra-species variability in physiology may result in varied drug disposition. Therefore, this critical review aims to collate data from pharmacological studies of selected NSAIDs and opioids performed in reptile and provide an analysis and discussion on the existing pharmacodynamic knowledge and pharmacokinetic data of NSAIDs and opioids use in reptiles. Additionally, key pharmacokinetic trends that may aid dosing of NSAIDs and opioids in reptiles will also be highlighted. Most of the existing reports of NSAID used in reptiles did not observe any adverse effects directly associated to the respective NSAID used, with meloxicam being the most well-studied. Despite the current absence of analgesic efficacy studies for NSAIDs in reptiles, most reports observed behavioural improvements in reptiles after NSAID treatment. Fentanyl and morphine were studied in the greatest number of reptile species with analgesic effects observed with the doses used, while adverse effects such as sedation were observed most with butorphanol use. While pharmacokinetic trends were drug- and species-specific, it was observed that clearance (CL) of drugs tended to be higher in squamates compared to chelonians. The half-life (t_1/2) of meloxicam also appeared to be longer when dosed orally compared to other routes of drug administration. This could have been due to absorption-rate limited disposition. Although current data provided beneficial information, there is an urgent need for future research on NSAID and opioid pharmacology to ensure the safe and effective use of opioids in reptiles.

Using the Intranasal Route to Administer Drugs to Treat Neurological and Psychiatric Illnesses: Rationale, Successes, and Future Needs

While the intranasal administration of drugs to the brain has been gaining both research attention and regulatory success over the past several years, key fundamental and translational challenges remain to fully leveraging the promise of this drug delivery pathway for improving the treatment of various neurological and psychiatric illnesses. In response, this review highlights the current state of understanding of the nose-to-brain drug delivery pathway and how both biological and clinical barriers to drug transport using the pathway can been addressed, as illustrated by demonstrations of how currently approved intranasal sprays leverage these pathways to enable the design of successful therapies. Moving forward, aiming to better exploit the understanding of this fundamental pathway, we also outline the development of nanoparticle systems that show improvement in delivering approved drugs to the brain and how engineered nanoparticle formulations could aid in breakthroughs in terms of delivering emerging drugs and therapeutics while avoiding systemic adverse effects.

Role of general anesthetic agents in postoperative nausea and vomiting: A review of literature

Postoperative nausea and vomiting (PONV) is considered to be the most unpleasant experience associated with surgery and is believed to be one of the most common reasons for poor patient satisfaction in the postoperative period. It also results in prolonged hospitalization and increased use of resources such as intravenous fluids and drug supplements along with prolonged medical attention, all of which have psychological and financial implications. In addition to this, PONV can result in aspiration, laryngospasm, dehydration, electrolyte disturbances, gastric bleeding, increased intracranial pressure, increased intraocular pressure, and wound dehiscence particularly when the surgical intervention is performed through an intraoral approach. It is a well-known fact that there are many etiological factors as well as predisposing factors for PONV. Hence, this review is intended to evaluate as an individual factor what the role was played by the anesthetic agents used for GA in the incidence of PONV.

HPV Lesions and Other Issues in the Oral Cavity Treatment and Removal without Pain

Due to different oral and dental conditions, oral mucosa lesions such as those caused by the human papilloma virus and temporomandibular joint pathologies often have to be treated by surgical, ablative or extractive procedures. The treatment and control of pain and inflammation during these procedures is essential to guarantee the patient's well-being. For the foregoing reason, a hydrogel based on sodium alginate and hyaluronic acid containing 2% of ketorolac tromethamine has been developed. We characterized it physically, mechanically and morphologically. The rheological results suggest that the formulation can be easily and gently applied. Ex vivo permeation studies show that Ketorolac Tromethamine is able to penetrate through the buccal and sublingual mucosae, in addition to being retained in the mucosae's structure. Through an in vitro test, we were able to evaluate the role that saliva plays in the bioavailability of the drug, observing that more than half of the applied dose is eliminated in an hour. The histological and cytotoxic studies performed on pigs in vivo showed the excellent safety profile of the formulation, as well as its high tolerability. In parallel, a biomimetic artificial membrane (PermeaPad^®) was evaluated, and it showed a high degree of correlation with the oral and sublingual mucosa.

Assessment of Antimicrobial Agents, Analgesics, and Epidermal Growth Factors-Embedded Anti-Adhesive Poly(Lactic-Co-Glycolic Acid) Nanofibrous Membranes: In vitro and in vivo Studies

Background

Postoperative tissue adhesion is a major concern for most surgeons and is a nearly unpreventable complication after abdominal or pelvic surgeries. This study explored the use of sandwich-structured antimicrobial agents, analgesics, and human epidermal growth factor (hEGF)-incorporated anti-adhesive poly(lactic-co-glycolic acid) nanofibrous membranes for surgical wounds.

Materials and Methods

Electrospinning and co-axial electrospinning techniques were utilized in fabricating the membranes. After spinning, the properties of the prepared membranes were assessed. Additionally, high-performance liquid chromatography and enzyme-linked immunosorbent assays were utilized in assessing the in vitro and in vivo liberation profiles of the pharmaceuticals and the hEGF from the membranes.

Results

The measured data suggest that the degradable anti-adhesive membranes discharged high levels of vancomycin/ceftazidime, ketorolac, and hEGF in vitro for more than 30, 24, and 27 days, respectively. The in vivo assessment in a rat laparotomy model indicated no adhesion in the peritoneal cavity at 14 days post-operation, demonstrating the anti-adhesive capability of the sandwich-structured nanofibrous membranes. The nanofibers also released effective levels of vancomycin, ceftazidime, and ketorolac for more than 28 days in vivo. Histological examination revealed no adverse effects.

Conclusion

The outcomes of this study implied that the anti-adhesive nanofibers with sustained release of antimicrobial agents, analgesics, and growth factors might offer postoperative pain relief and infection control, as well as promote postoperative healing of surgical wounds.

Foot and Ankle Injections in Athletes

CONTEXT

Injections are commonly used by health care practitioners to treat foot and ankle injuries in athletes despite ongoing questions regarding efficacy and safety.

EVIDENCE ACQUISITION

An extensive literature review was performed through MEDLINE, Google Scholar, and EBSCOhost from database inception to 2021. Keywords searched were injections, athletes, sports, foot and ankle, corticosteroids, platelet-rich plasma, and placental tissue. Search results included articles written in the English language and encompassed reviews, case series, empirical studies, and basic science articles.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

Corticosteroids, platelet-rich plasma/autologous blood, anesthetic, and placental tissue injections are commonly used in the treatment of foot and ankle injuries. Primary indications for injections in athletes include plantar fasciitis, Achilles tendinosis, isolated syndesmotic injury, and ankle impingement with varying clinical results.

CONCLUSIONS

Despite promising results from limited case series and comparative studies, the data for safety and efficacy of injections for foot and ankle injuries in athletes remain inconclusive.

Injectable Ketorolac and Corticosteroid Use in Athletes: A Systematic Review

CONTEXT

The use of injectable medications to help athletes quickly return to the field of play after injury is common. Understanding the effects and risks of these medications will help providers make informed decisions regarding their use in this patient population.

OBJECTIVE

To evaluate the utilization, efficacy, and adverse effects of injectable ketorolac and corticosteroids in athletes.

DATA SOURCES

This systematic review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A systematic search of the literature was performed using multiple databases (PubMed, Embase, Cochrane, Web of Science, and ClinicalTrials.gov). Secondary references were appraised for relevant articles. No randomized controlled trials or other prospective studies were identified. Articles included retrospective database reviews and physician survey studies.

STUDY SELECTION

A total of 6 studies met the inclusion and exclusion criteria and were reviewed by 2 independent reviewers with a third consulted in the case of disagreement, which was not needed.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 5.

DATA EXTRACTION

Two reviewers recorded rate of use, effectiveness of treatment, and reported side effect data.

RESULTS

Most studies centered around the football athlete, either professional or collegiate. Professional football game day use of intramuscular ketorolac declined from 93.3% (28/30) in 2002 to 48% in 2016. Collegiate football game day use of intramuscular ketorolac declined from 62% in 2008 to 26% in 2016. Game day corticosteroid injection was far lower than ketorolac usage. Both medications were reported to be effective with few adverse events.

CONCLUSION

Use of injectable ketorolac is common but declining in professional and college football. Pain control efficacy is good, and risk of adverse events is low. The incidence of injectable corticosteroid use in athletes is unknown. Use of injectable corticosteroids in athletes allows for early return to sport activities with no reported complications.

Effects of the pestle needle therapy, a type of acupoint stimulation, on post-hemorrhoidectomy pain: A randomized controlled trial

BACKGROUND

Hemorrhoids are one of the most common conditions that lead to surgery, and until now surgical hemorrhoidectomy has been the major effective treatment. Post-operative pain from hemorrhoidectomy has been experienced by thousands of patients and remains a major inconvenience of the operation.

OBJECTIVE

This study evaluates the clinical efficacy of the pestle needle therapy, an acupoint stimulation method, for relief of post-hemorrhoidectomy pain.

DESIGN, SETTING, PARTICIPANTS AND INTERVENTIONS

This was a single-center, patient-assessor-blinded and randomized controlled trial with 154 patients receiving Milligan hemorrhoidectomy surgery. Eligible patients were randomly assigned to either a treatment group or a control group at a ratio of 1:1. The treatment group received the pestle needle therapy, with manual stimulation at Yaoshu (DU2), Mingmen (DU4), Changqiang (DU1), Chengshan (BL57), Erbai (EX-UE2) and the perianal points (1, 3, 5, 7, 9, and 11o'clock around the lesion); while the control group received a sham treatment with very light pressure. Three sessions of treatment were performed at 30 min, 4 h and 12 h after the surgery, and each lasted for 15 min.

MAIN OUTCOME MEASURES

The primary outcome was post-operative pain measured with the visual analogue scale (VAS) at 12 h after surgery. The secondary outcomes included the VAS scores measured at 0.5, 2, 4, 6, 8, 24 and 48 h after surgery, the analgesic dose, the time and the VAS score of the patients' first defecation after surgery, as well as the Hamilton Rating Scale for Anxiety (HAMA) evaluated before discharge.

RESULTS

The mean pain score of the treatment group was significantly lower than that of the control group (3.10 ± 1.27 vs 4.82 ± 1.29; P < 0.001) at 12 h after surgery. Compared with the control group, patients in the treatment group needed a smaller dose of analgesic within the first 24 hours after surgery (P = 0.002); and their HAMA scores before discharge were lower (4.07 ± 2.40 vs 5.10 ± 2.45, P = 0.009). Compared to the treatment group, patients in the control group had a greater time to the first defecation after surgery ([52.34 ± 15.72] h vs [27.08 ± 13.68] h; P < 0.001), but there was no difference in their VAS scores at the first defecation (P = 0.092).

CONCLUSION

The pestle needle therapy was effective for relieving pain, reducing anxiety and improving bowel function after hemorrhoidectomy, and it is worthy of clinical application.

A prospective randomized trial of intravenous ketorolac vs. acetaminophen administered with opioid patient-controlled analgesia in gynecologic surgery

OBJECTIVE

To determine which non-narcotic analgesic, acetaminophen (Ofirmev®) or ketorolac (Toradol®), provides better post-operative pain control when combined with an opioid patient-controlled analgesia (PCA) pump. Secondary objectives include comparisons of the rates of ileus, post-operative bleeding, transfusions, and length-of-hospitalization (LOH).

METHODS

A prospective, randomized trial of acetaminophen (A) 1-g intravenous (IV) every 6-h or ketorolac (K) 15-mg IV every 6-h from post-operative day 1-3 in addition to an opioid PCA for patients undergoing benign or malignant gynecologic laparotomy procedures was performed. Abstracted data included pain levels via visual analogue pain scales (VAS), amount of narcotic used, hepatic enzyme levels, hemoglobin, urine output, blood transfusions, time to return of flatus and LOH.

RESULTS

One-hundred patients were accrued and underwent 55 benign gynecologic laparotomies and 45 cancer-related laparotomies. VAS pain levels (3.3 K, 3.5 A) and morphine PCA use (79.1 oral morphine equivalents [OME] K vs. 84.5 A) were not different, however dilaudid PCA usage was less by K patients (84.4 OME K and 136.8 OME A, p < 0.001). There was a significant hemoglobin change between the two groups (2.6 g K vs. 2 g A, p = 0.015), however blood transfusions were equal (28% K, 22% A, p > 0.05). Return of flatus was 2.7-days for K vs. 3.4-days for A (p = 0.011) and LOH was not different (4.4-days K vs. 5.1-days A, p = 0.094).

CONCLUSIONS

Both intravenous ketorolac and acetaminophen provide similar post-operative analgesia through VAS pain scales and total usage of morphine via PCA pumps. Use of ketorolac with dilaudid PCA was associated with less dependence on dilaudid and a quicker return of bowel function than acetaminophen, however length of stay and transfusion rates were not different.

Population Pharmacokinetics of Periarticular Ketorolac in Adult Patients Undergoing Total Hip or Total Knee Replacement Surgery

BACKGROUND

Ketorolac tromethamine has been used for joint infiltration by the orthopedic surgeons as a part of postoperative multimodal analgesia. The objective of this study is to investigate the pharmacokinetic properties of S (-) and R (+) enantiomers of ketorolac in adult patients undergoing total hip (THA) and knee arthroplasty (TKA).

METHODS

Adult patients with normal preoperative renal function received a periarticular infiltration of 30 mg of ketorolac tromethamine along with 100 mL of 0.2% ropivacaine and 1 mg of epinephrine at the end of their THA or TKA surgery. Blood samples were taken from a venous cannula at various time points after infiltration. Pharmacokinetic modeling was performed using PMetrics 1.5.0.

RESULTS

From 18 participants, 104 samples were analyzed. The peak plasma concentration for S (-) ketorolac was found to be lower than that of R (+) ketorolac, for both THA (0.19-1.22 mg/L vs 0.39-1.63 mg/L, respectively) and TKA (0.28-0.60 mg/L vs 0.48-0.88 mg/L, respectively). The clearance of the S (-) ketorolac enantiomer was higher than R (+) ketorolac (4.50 ± 2.27 vs 1.40 ± 0.694 L/h, respectively).

CONCLUSIONS

Our study demonstrates that with periarticular infiltration, S (-) ketorolac was observed to have increased clearance rate and highly variable volume of distribution and lower peak plasma concentration compared to R (+) ketorolac.

New drug candidates for bipolar disorder-A nation-wide population-based study

OBJECTIVE

Drug repurposing is an increasingly promising idea in many fields of medicine. We systematically used Danish nation-wide population-based registers to investigate whether continued use of non-aspirin non-steroidal anti-inflammatory drugs (NSAIDs), low-dose aspirin, high-dose aspirin, statins, allopurinol, and angiotensin agents decrease the rate of incident mania/bipolar disorder.

METHODS

A nation-wide population-based longitudinal study using Poisson regression analyses including all persons in Denmark who purchased the exposure medication of interest and a random sample of 30% of the Danish population. The follow-up period comprised a 10 years period from 2005 to 2015. Two different outcome measures were included, (1) a diagnosis of mania/bipolar disorder at a psychiatric hospital contact as inpatient or outpatient and (2) a combined measure of a diagnosis of mania/bipolar disorder or initiation of lithium use.

RESULTS

A total of 1,605,365 subjects were exposed to one of the six drugs of interest during the exposure period from 2005 to 2015, median age 57 years [quartiles: 43;69], and female proportion of 53.1%. Continued use of low-dose aspirin, statins, and angiotensin agents were associated with decreased rates of incident mania/bipolar disorder on both outcome measures. Continued uses of non-aspirin NSAIDs as well as high-dose aspirin were associated with an increased rate of incident bipolar disorder. There were no statistically significant associations for allopurinol.

CONCLUSIONS

The study supports the potential of agents acting on inflammation and the stress response system in bipolar disorder and illustrates that population-based registers can be used to systematically identify drugs with repurposing potentials.

Efficacy of pethidine, ketorolac, and lidocaine gel as analgesics for pain control in shockwave lithotripsy: A single-blinded randomized controlled trial

Purpose

To compare the safety and efficacy of xylocaine gel and ketorolac as opioid-sparing analgesia compared with pethidine for shock wave lithotripsy (SWL) pain.

Materials and Methods

A single-blinded randomized controlled trial (RCT) was performed in 132 patients with renal and upper ureteral stones amenable to treatment with SWL. The first patient group received intravenous (IV) pethidine and placebo gel; the second group received IV ketorolac plus placebo gel; the third group received lidocaine gel locally plus normal saline IV. Stone disintegration was classified as none (no change from basal by kidney, ureter, bladder X-ray or ultrasound [US] imaging), partial (fragmented and >4-mm residual fragments), and complete (≤4-mm residual fragments). Stone disintegration was assessed by kidney-ureter-bladder X-ray and US imaging. Pain was evaluated by use of the Numeric Pain Rating Scale (NPRS).

Results

The NPRS scores were highest in the xylocaine group at 10, 20, and 30 minutes (p=0.0001) with no significant difference between the ketorolac and pethidine groups, except at 10 minutes (p=0.03) and a near significant difference at 30 minutes (p=0.054) in favor of ketorolac. Results for stone disintegration (none, partial, and complete, respectively) were as follows: 25 (50.0%), 23 (46.0%), and 2 (4.0%) for pethidine; 19 (35.8%), 23 (43.4%), and 11 (20.8%) for ketorolac; and 26 (89.7%), 3 (10.3%), and 0 (0.0%) for lidocaine (p=0.008).

Conclusions

Ketorolac is a safe and more effective alternative to morphine derivatives for SWL analgesia. Lidocaine gel should not be used as mono-analgesia for SWL.

Perioperative Ketorolac Use and Postoperative Hematoma Formation in Reduction Mammaplasty: A Single-Surgeon Experience of 500 Consecutive Cases

BACKGROUND

In light of the escalating opioid crisis, surgeons are increasingly focused on minimizing opioid use. Ketorolac has well-documented opioid-sparing effects in the postoperative period; however, its use is limited because of concerns of postoperative bleeding and hematoma formation. This study explores the relationship between hematoma formation and administration of perioperative ketorolac in adolescent female patients and young adult women undergoing reduction mammaplasty. It also aims to determine the effect of perioperative ketorolac administration on the requirement for opioid analgesia.

METHODS

The authors reviewed the medical records of 500 consecutive female patients who underwent reduction mammaplasty for bilateral macromastia from 2007 to 2017. The authors collected data pertaining to perioperative analgesia use and postoperative hematoma formation.

RESULTS

Five-hundred patients were included in analyses. The average age of the patients was 18.1 ± 2.2 years. Three hundred eighty-nine patients (77.8 percent) received intravenous ketorolac during the perioperative period. Seven patients (1.4 percent) developed a postoperative hematoma. Hematoma was not associated with intraoperative, postoperative, and perioperative ketorolac use (p > 0.43, all). Intraoperative ketorolac use was associated with lower total intraoperative dosing of fentanyl and morphine, and postoperative ketorolac use was associated with lower total postoperative doses of oxycodone and morphine (p < 0.001, all).

CONCLUSIONS

Ketorolac use was largely associated with decreased perioperative opioid use, but not with hematoma formation. Ketorolac may be a safe alternative to opioids in adolescents and young women undergoing reduction mammaplasty without increasing the risk of hematoma formation.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

New drug candidates for depression - a nationwide population-based study

OBJECTIVE

To investigate whether continued use of non-aspirin NSAID, low-dose aspirin, high-dose aspirin, statins, allopurinol and angiotensin agents decreases the rate of incident depression using Danish nationwide population-based registers.

METHODS

All persons in Denmark who purchased the exposure medications of interest between 1995 and 2015 and a random sample of 30% of the Danish population was included in the study. Two different outcome measures were included, (i) a diagnosis of depressive disorder at a psychiatric hospital as in-patient or out-patient and (ii) a combined measure of a diagnosis of depression or use of antidepressants.

RESULTS

A total of 1 576 253 subjects were exposed to one of the six drugs of interest during the exposure period from 2005 to 2015. Continued use of low-dose aspirin, statins, allopurinol and angiotensin agents was associated with a decreased rate of incident depression according to both outcome measures. Continued uses of non-aspirin NSAIDs as well as high-dose aspirin were associated with an increased rate of incident depression.

CONCLUSION

The findings support the potential of agents acting on inflammation and the stress response system in depression as well as the potential of population-based registers to systematically identify drugs with repurposing potential.

Injectable Nonsteroidal Anti-Inflammatory Drugs in Sport

OBJECTIVE

The primary objective of this article is to review the basic science of nonsteroidal anti-inflammatory drugs (NSAIDs), their clinical effects, indications, potential complications, and ethical issues associated with the use of injectable NSAIDs in the treatment of athletes. These objectives are presented taking into consideration the contemporaneous issues associated with the treatment of amateur and professional athletes.

DATA SOURCES

A nonformal review of the published medical literature and lay media focusing on the use of injectable NSAIDs in athletes was used for this article.

MAIN RESULTS

All NSAIDs work through the inhibition of the cyclooxygenase (COX) pathway (either one or both subtypes) to reduce inflammation and inhibit pain by reducing prostaglandin and thromboxane synthesis. Complications related to NSAID use involve primarily the gastrointestinal, renal, and cardiovascular systems through this COX pathway inhibition. Ketorolac is the only NSAID currently available in an injectable form. Despite its analgesic efficacy comparable with opioid medication, injectable ketorolac has the potential to cause bleeding in collision athletes resulting from impaired hemostasis.

CONCLUSIONS

Nonsteroidal anti-inflammatory drug medications are currently used at every level of competition. Injectable ketorolac is an effective analgesic and anti-inflammatory drug. However, its potential effectiveness must be weighed against the risk of potential complications in all athletes, especially those who participate in contact/collision sports. The team physician must balance the goal of treating pain and inflammation with the ethical implications and medical considerations inherent in the administration of injectable medications solely to prevent pain and/or return the athlete to competition.

Repercussion of nonsteroidal anti-inflammatory drugs on the gene expression of human osteoblasts

Background

Nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently used in clinical practice, which can have adverse effects on the osteoblast. The objective of this study was to determine the effect of NSAIDs on the osteoblast by analyzing the gene expression of different markers related to osteoblast maturation and function when treated in vitro with different NSAIDs.

Methods

Three human osteoblast lines from bone samples of three healthy volunteers were treated with 10 µM acetaminophen, indomethacin, ketoprofen, diclofenac, ibuprofen, ketorolac, naproxen, and piroxicam. The gene expression of different markers (run related transcription factor 2 [RUNX-2], type 1 collagen [COL-I], osterix [OSX], osteocalcin [OSC], bone morphogenetic protein 2 [BMP-2] and 7 [BMP-7], transforming growth factor β1 [TGF-β1], and TGFβ receptors [TGFβR1, TGFβR2; TGFBR3]) were analyzed by real-time PCR at 24 h of treatment.

Results

Expression of RUNX-2, COL-I, OSX, was reduced by treatment with all studied NSAIDs, OSC expression was reduced by all NSAIDs except for ketoprofen, naproxen, or piroxicam. Expression of BMP-7 was reduced by all NSAIDs; BMP-2 was reduced by all except for naproxen. In general, NSAID treatment increased the expression of TGF-β1, but not of its receptors (TGFβ-R1, TGFβ-R2, andTFGβ-R3), which was either unchanged or reduced by the treatment.

Conclusion

These data confirm that NSAIDs can affect osteoblast physiology, suggesting their possible impact on bone.

Mucosal co-delivery of ketorolac and lidocaine using polymeric wafers for dental application

The current study aimed to investigate the effectiveness of a developed sodium alginate and polyvinylpyrrolidone K-25 (PVP K-25) polymeric wafer for the co-delivery of ketorolac and lidocaine to soft tissues for healing and pain control following gingivectomy. Nine ketorolac/lidocaine lyophilized wafers were formulated and assessed for their hydration capacity, mucoadhesion ability and in vitro release profile to select the optimum system for further clinical investigation. Wafer F6 containing 2:1 sodium alginate to PVP K-25 and 10% glycerol showed optimum properties and was selected for the clinical study. Twenty patients were included in the study and the ketorolac/lidocaine wafer was assessed versus a market product. Visual pain analog was evaluated daily for the first week and wound healing index was evaluated for one week, two weeks and one month following the procedure. The developed ketorolac/lidocaine polymeric wafer proved to be an effective method of reducing pain and discomfort together with enhancing wound healing following gingivectomy.

Continuous Subcutaneous Infusion of Ketorolac in Cancer Neuropathic Pain Unresponsive to Opioid and Adjuvant Drugs. A Case Report

Ketorolac is a new non-steroidal anti-inflammatory drug (NSAID) having a potent nonopioid analgesic activity. Administered by continuous subcutaneous infusion (CSI), its analgesic efficacy has been documented in the treatment of somatic and visceral cancer pain whilst it has been shown to be ineffective in the treatment of neuropathic pain. Here is a description of a cancer patient with neuropathic pain unresponsive to anticonvulsant or antidepressant drugs administered in association or not with oral opioids but who was successfully treated with ketorolac alone via CSI. Furthermore, the analgesia lasted over 75 days of treatment without any significant renal and gastric side effects.

Narrative review shows that the short-term use of ketorolac is safe and effective in the management of moderate-to-severe pain in children

In June 2013, the European Medicine Agency recommended limiting codeine use in paediatric patients, creating a void in managing moderate pain. We reviewed the literature published in English (1985-June 2017) on the pharmacokinetic, pharmacodynamic and safety profile of ketorolac, a possible substitute for codeine and opioids, for treating moderate-to-severe pain. We found that gastrointestinal side effects were mainly reported with prolonged use, significant bleeding was reported in adenotonsillectomy, and adverse renal effects appeared to be limited to patients with specific coexisting risk factors.

CONCLUSION

The short-term use of ketorolac appears to be safe for children in many situations.

Acute kidney injury in octogenarians after heart valve replacement surgery: a study of two periods over the last decade

Background

Data on postoperative acute kidney injury (AKI) in octogenarians are limited. This study examines the AKI occurrence and clinical impact in octogenarians following open-heart valve replacement surgery in two periods over the last 15 years.

Methods

A total of 452 consecutive octogenarians (non–kidney transplant and non-dialysis) who underwent heart valve replacement at the Mayo Clinic during the years 2011–13 (contemporary cohort) were examined. The results were compared with a comparable 209 consecutive octogenarians in 2002–03 (past cohort). Pre-existing chronic kidney disease (CKD) was defined based on estimated glomerular filtration rate (Chronic Kidney Disease Epidemiology Collaboration formula). Outcomes included postoperative AKI defined by the Acute Kidney Injury Network (AKIN) criteria, length of hospital stay (LOS), discharge disposition and patient survival (hospital and 1 year).

Results

AKI occurrence in the contemporary cohort was lower than the past cohort (35% versus 47%, respectively, P < 0.003). Compared with the past cohort, the contemporary cohort had fewer known perioperative AKI risk factors (pre-existing CKD, comorbidity, heart failure, surgical duration, cross-clamp time, blood transfusion and large-volume intravenous fluids). In both periods, AKI adversely impacts mortality, LOS and discharge to a care facility.

Conclusions

Postoperative AKI in octogenarians following heart valve replacement surgery has declined over the last decade. As a result, the AKI-attributable percentage mortality has accordingly decreased. However, AKI continues to exert a heavy morbidity and mortality burden. These results are highly pertinent to practice since the octogenarian population is growing.

A synthesis of functionalized dihydro-1Η-pyrrolizines and spiropyrrolizines via [2 + 3] cycloaddition reactions

A one-pot synthesis of dihydro-1H-pyrrolizine derivatives via [Formula: see text] cycloaddition reaction of azomethine ylides, prepared in situ from proline and ninhydrin, with dialkyl acetylenedicarboxylates, in alcohols, is described. When sarcosine was used instead of proline, functionalized spiropyrrolizines were obtained. Under these conditions, alkyl propiolates produced stable spirans.

Drug Dosing in Critically Ill Patients with Renal Failure: A Pharmacokinetic Approach

Accurate pharmacotherapy management in the intensive care unit (ICU) patient is crucial to minimize adverse drug events. Pharmacokinetic principles including absorption, distribution, metabolism, and excretion (ADME) all play an important role in determining the fate of medications used in the critical care setting. Renal failure in this setting further alters pharmacokinetic parameters, resulting in drug dosing changes. This article highlights and applies principles of drug dosing in normal patients and in the pharmacokinetically challenging environment of critically ill patients with renal failure. Specific drug dosing tables serve as a guide for the clinician to renally adjust medication doses in the critically ill patient with renal failure.

Spinal activity of interleukin 6 mediates myelin basic protein-induced allodynia

Mechanosensory fibers are enveloped by myelin, a unique multilamellar membrane permitting saltatory neuronal conduction. Damage to myelin is thought to contribute to severe pain evoked by innocuous tactile stimulation (i.e., mechanical allodynia). Our earlier (Liu et al., 2012) and present data demonstrate that a single injection of a myelin basic protein-derived peptide (MBP84-104) into an intact sciatic nerve produces a robust and long-lasting (>30days) mechanical allodynia in female rats. The MBP84-104 peptide represents the immunodominant epitope and requires T cells to maintain allodynia. Surprisingly, only systemic gabapentin (a ligand of voltage-gated calcium channel α2δ1), but not ketorolac (COX inhibitor), lidocaine (sodium channel blocker) or MK801 (NMDA antagonist) reverse allodynia induced by the intrasciatic MBP84-104. The genome-wide transcriptional profiling of the sciatic nerve followed by the bioinformatics analyses of the expression changes identified interleukin (IL)-6 as the major cytokine induced by MBP84-104 in both the control and athymic T cell-deficient nude rats. The intrasciatic MBP84-104 injection resulted in both unilateral allodynia and unilateral IL-6 increase the segmental spinal cord (neurons and astrocytes). An intrathecal delivery of a function-blocking IL-6 antibody reduced the allodynia in part by the transcriptional effects in large-diameter primary afferents in DRG. Our data suggest that MBP regulates IL-6 expression in the nervous system and that the spinal IL-6 activity mediates nociceptive processing stimulated by the MBP epitopes released after damage or disease of the somatosensory nervous system.

Studies on methylcellulose/pectin/montmorillonite nanocomposite films and their application possibilities

Films based on methylcellulose (MC) and pectin (PEC) of different ratios were prepared. MC/PEC (90:10) (MP10) gave the best results in terms of mechanical properties. Sodium montmorillonite (MMT) (1, 3 and 5 wt%) was incorporated in the MP10 matrix. The resulting films were characterized by X-ray diffraction and transmission electron microscopy, and it was found that nanocomposites were intercalated in nature. Mechanical studies established that addition of 3 wt% MMT gave best results in terms of mechanical properties. However, thermo-gravimetric and dynamic mechanical analysis proved that decomposition and glass transition temperature increased with increasing MMT concentration from 1 to 5 wt%. It was also observed that moisture absorption and water vapor permeability studies gave best result in the case of 3 wt% MMT. Optical clarity of the nanocomposite films was not much affected with loading of MMT. In vitro drug release studies showed that MC/PEC/MMT based films can be used for controlled transdermal drug delivery applications.

Increased Risk of End-Stage Renal Disease (ESRD) Requiring Chronic Dialysis is Associated With Use of Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Nationwide Case-Crossover Study

It is known that many medical adverse events can be caused by nonsteroidal anti-inflammatory drugs (NSAIDs); however, epidemiologic evidence has not granted an affirmative relationship between NSAID use and the risk of end-stage renal disease (ESRD). We aimed to investigate the relationship in a Chinese population between short-term NSAID use and development of ESRD requiring chronic dialysis. A retrospective case-crossover design was used in this study. Using the Taiwanese National Health Insurance database, we identified 109,400 incident chronic ESRD patients with dialysis initiation from 1998 to 2009. For each patient, we defined the case period as 1 to 14 days and the control period as 105 to 118 days, respectively, before the first dialysis date. The washout period was 90 days between the case and control period. Detailed information about NSAID use was compared between the case and control periods. We calculated odds ratios (ORs) and their 95% confidence intervals (CIs) using a conditional logistic regression model. NSAID use was found to be a significant risk factor associated with dialysis commencement. The adjusted OR was 2.73 (95% CI: 2.62-2.84) for nonselective NSAIDs and 2.17 (95% CI: 1.83-2.57) for celecoxib. The OR reached 3.05 for the use of acetic acid derivatives. Compared with the oral forms, significantly higher risks were seen in parenteral NSAID use (OR: 8.66, 95% CI: 6.12-20.19). NSAIDs should be prescribed with caution, especially for those in ESRD high-risk groups.

Enhancement of ketorolac tromethamine permeability through rat skin using penetration enhancers: An ex-vivo study

Introduction:

Ketorolac tromethamine (KT), a nonsteroidal anti-inflammatory drug, when given orally causes gastrointestinal disturbances. Its transdermal drug delivery may reduce such side effects associated with them. The present investigation was aimed at evaluating the efficiency of various penetration enhancers for improved permeation of KT through the skin.

Materials and Methods:

A concentration of 1 mg/mL of the drug solution with enhancers was used to evaluate diffusion through the rat skin using a Franz diffusion cell assembly. 20 different penetration enhancers were selected for this study.

Results:

Saturated fatty acids like stearic and palmitic acid were found to increase the permeation rate of the drug to a great extent whereas unsaturated fatty acid viz. oleic acid exhibited maximum permeation. Increase in permeability efficiency of various penetration enhancers was observed in the following order: Oleic acid > stearic acid > palmitic acid > isopropyl myristate > tween 80 > span 80 > span 40 > span 20 > l-limonene > l-menthol > fenchone > α-pinene > urea > dimethyl sulfoxide (DMSO) > triton X-100 > tween 20 > dimethyl formamide > acetone > control > citric acid > ascorbic acid. Ascorbic acid and citric acid had no effect on permeation rate.

Conclusion:

The results revealed that the permeation of KT through the skin can maximally be enhanced using oleic acid-an unsaturated fatty acid.

Is ketorolac safe to use in plastic surgery? A critical review

BACKGROUND

Ketorolac tromethamine is a nonsteroidal anti-inflammatory drug (NSAID) that provides postoperative pain control and reduces narcotic requirements. However, concerns regarding postoperative hematoma have limited its use in plastic surgery.

OBJECTIVES

Our goal is to critically review the risk of bleeding with ketorolac in plastic surgery patients, with a focus on aesthetic surgery.

METHODS

A PubMed/Medline literature search of clinical trials using the keywords "surgery" and "NSAID" yielded 2574 results. Of these results, 1036 included ketorolac and twelve involved plastic surgery patients. Six studies reported postoperative hematoma rates: three prospective randomized trials, two retrospective reviews, and one case series. These were subjected to statistical analysis to determine if an association existed between ketorolac and postoperative hematomas.

RESULTS

Six papers reported 981 cases. Ketorolac use resulted in similar hematoma rates when compared to control groups, 2.5% (12 of 483) versus 2.4% (12 of 498), respectively (P = .79). There were no reported hematomas associated with ketorolac in over 115 patients undergoing aesthetic facial procedures. Hematoma rates of those undergoing aesthetic breast surgery, including reduction and augmentation mammoplasties, were 4.3% (11 of 257) in the ketorolac group versus 2.2% (6 of 277) in controls (P = .59). Reduction in postoperative narcotic use and improved pain scores was also reported.

CONCLUSIONS

Our literature review did not find a significant association between hematoma formation and ketorolac use in a variety of plastic surgery procedures. These findings are similar to those in other surgical subspecialties.

Prodrug strategies for enhancing the percutaneous absorption of drugs

The transdermal application of drugs has attracted increasing interest over the last decade or so, due to the advantages it offers, compared to other delivery methods. The development of an efficient means of transdermal delivery can increase drug concentrations, while reducing their systemic distribution, thereby avoiding certain limitations of oral administration. The efficient barrier function of the skin, however, limits the use of most drugs as transdermal agents. This limitation has led to the development of various strategies to enhance drug-skin permeation, including the use of penetration enhancers. This method unfortunately has certain proven disadvantages, such as the increased absorption of unwanted components, besides the drug, which may induce skin damage and irritancy. The prodrug approach to increase the skin’s permeability to drugs represents a very promising alternative to penetration enhancers. The concept involves the chemical modification of a drug into a bioreversible entity that changes both its pharmaceutical and pharmacokinetic characteristics to enhance its delivery through the skin. In this review; we report on the in vitro attempts and successes over the last decade by using the prodrug strategy for the percutaneous delivery of pharmacological molecules.