Ketorolac (Solution) Instructions for Use

ATC Code

M01AB15 (Ketorolac)

Active Substance

Ketorolac (Rec.INN registered by WHO)

Clinical-Pharmacological Group

NSAIDs with pronounced analgesic action

Pharmacotherapeutic Group

Nonsteroidal anti-inflammatory and antirheumatic drugs; acetic acid derivatives and related substances

Pharmacological Action

NSAID, exerts a pronounced analgesic effect, also has anti-inflammatory and moderate antipyretic action.

The mechanism of action is associated with non-selective inhibition of the activity of COX-1 and COX-2 enzymes, mainly in peripheral tissues, resulting in the inhibition of prostaglandin biosynthesis – modulators of pain sensitivity, inflammation, and thermoregulation. Ketorolac is a racemic mixture of R(+) and S(-)-enantiomers, with the analgesic effect being due to the S(-)-enantiomer.

Ketorolac does not affect opioid receptors, does not depress respiration, does not cause drug dependence, and does not have sedative or anxiolytic action.

In terms of the strength of the analgesic effect, it is comparable to morphine and significantly exceeds other NSAIDs.

After intramuscular administration, the onset of analgesic action is noted after 0.5 hours, the maximum effect is achieved after 1-2 hours.

Pharmacokinetics

After intramuscular administration, absorption is complete and rapid. After intramuscular administration of the drug at a dose of 30 mg, C_max in blood plasma is 1.74-3.1 µg/ml, at a dose of 60 mg – 3.23-5.77 µg/ml. T_max is 15-73 min and 30-60 min, respectively.

After intravenous infusion of the drug at a dose of 15 mg, C_max is 1.96-2.98 µg/ml, at a dose of 30 mg – 3.69-5.61 µg/ml.

Binding to plasma proteins is 99%. In hypoalbuminemia, the amount of free substance in the blood increases.

V_d is 0.15-0.33 l/kg.

C_ss with parenteral administration is achieved after 24 hours when used 4 times/day (above subtherapeutic) and with intramuscular administration at a dose of 15 mg is 0.65-1.13 µg/ml, with intramuscular administration at a dose of 30 mg – 1.29-2.47 µg/ml; with intravenous infusion at a dose of 15 mg – 0.79-1.39 µg/ml, with intravenous infusion at a dose of 30 mg – 1.68-2.76 µg/ml.

It poorly passes through the blood-brain barrier, penetrates the placental barrier (10%).

With parenteral administration, it is excreted in breast milk in small amounts.

More than 50% of the administered dose is metabolized in the liver with the formation of pharmacologically inactive metabolites. The main metabolites are glucuronides and p-hydroxyketorolac.

Excreted in urine – 91% (40% as metabolites), in feces – 6%. It is not removed by hemodialysis.

After intramuscular administration of 30 mg, T_1/2 is 3.5-9.2 hours, after intravenous administration of 30 mg, T_1/2 is 4-7.9 hours.

Total clearance with intramuscular administration of 30 mg is 0.023 l/kg/h, with intravenous infusion of 30 mg – 0.03 l/kg/h.

In patients with renal failure, the V_d of ketorolac may double, and the V_d of its R-enantiomer may increase by 20%. With a plasma creatinine concentration of 19-50 mg/l with intramuscular administration of 30 mg of the drug, total clearance is 0.015 l/kg/h.

In patients with impaired renal function with a plasma creatinine concentration of 19-50 mg/l (168-442 µmol/l), T_1/2 is 10.3-10.8 hours, with more severe renal failure – more than 13.6 hours.

Liver function does not affect T_1/2.

In elderly patients, total clearance with intramuscular administration at a dose of 30 mg is 0.019 l/kg/h. T_1/2 is prolonged in elderly patients and shortened in young patients.

Indications

Pain syndrome of severe and moderate intensity: trauma, toothache, pain in the postoperative period, oncological diseases, myalgia, arthralgia, neuralgia, radiculitis, dislocations, sprains, rheumatic diseases.

Intended for symptomatic therapy, reducing pain and inflammation at the time of use, does not affect the progression of the disease.

ICD codes

Dosage Regimen

Solution

It is set individually, depending on the patient’s age and the severity of the pain syndrome. With intramuscular or intravenous administration, a single dose can vary from 10 mg to 60 mg.

The maximum daily dose for intramuscular and intravenous administration for adults under 65 years of age and children over 16 years of age is 90 mg; for elderly patients (over 65 years of age) or with impaired renal function – 60 mg.

Continuous intravenous infusion should not last more than 24 hours.

With parenteral administration, the duration of the course of treatment should not exceed 5 days.

When switching from parenteral administration to oral administration, the total daily dose of ketorolac in both dosage forms on the day of transition should not exceed: 90 mg for adults under 65 years of age and children over 16 years of age and 60 mg – for elderly patients (over 65 years of age) or with impaired renal function. In this case, the dose of ketorolac for oral administration on the day of transition should not exceed 30 mg.

Adverse Reactions

From the digestive system: frequently (especially in elderly patients over 65 years of age, with a history of erosive and ulcerative lesions of the gastrointestinal tract) – gastralgia, diarrhea; less frequently – stomatitis, flatulence, constipation, vomiting, feeling of stomach fullness; rarely – decreased appetite, nausea, erosive and ulcerative lesions of the gastrointestinal tract (including with perforation and/or bleeding – abdominal pain, spasm or burning in the epigastric region, melena, vomiting of blood or coffee-ground vomit, nausea, heartburn), cholestatic jaundice, hepatitis, hepatomegaly, acute pancreatitis.

From the urinary system: rarely – acute renal failure, lower back pain, hematuria, azotemia, hemolytic-uremic syndrome (hemolytic anemia, renal failure, thrombocytopenia, purpura), frequent urination, increase or decrease in urine volume, nephritis, edema of renal origin.

From the nervous system: frequently – headache, dizziness, drowsiness; rarely – aseptic meningitis (including fever, severe headache, convulsions, rigidity of the neck and/or back muscles), hyperactivity (including mood changes, anxiety), hallucinations, depression, psychosis.

From the cardiovascular system: less frequently – increased blood pressure; rarely – fainting.

From the respiratory system: rarely – bronchospasm, dyspnea, rhinitis, pulmonary edema, laryngeal edema (including shortness of breath, difficulty breathing).

From the sensory organs rarely – hearing loss, ringing in the ears, visual impairment (including blurred vision).

From the hematopoietic system: rarely – anemia, eosinophilia, leukopenia.

From the blood coagulation system rarely – bleeding from the postoperative wound, nosebleed, rectal bleeding.

From the skin and subcutaneous tissues less frequently – skin rash (including maculopapular), purpura; rarely – exfoliative dermatitis (including fever with/without chills, redness, induration or peeling of the skin, swelling and/or soreness of the tonsils), urticaria, Stevens-Johnson syndrome, Lyell’s syndrome.

Allergic reactions rarely – anaphylaxis or anaphylactoid reactions (including facial skin discoloration, skin rash, urticaria, skin itching, tachypnea or dyspnea, eyelid edema, periorbital edema, shortness of breath, difficulty breathing, chest tightness, wheezing).

Local reactions less frequently – burning or pain at the injection site.

Other: frequently – edema (including face, shins, ankles, fingers, feet), weight gain; less frequently – increased sweating; rarely – tongue edema, fever.

Contraindications

Hypersensitivity to ketorolac and other NSAIDs; complete or incomplete combination of bronchial asthma, recurrent polyposis of the nose and paranasal sinuses and intolerance to acetylsalicylic acid or other NSAIDs (including in history); urticaria, rhinitis caused by taking NSAIDs (in history); intolerance to drugs of the pyrazolone series; dehydration, hypovolemia (regardless of the cause); bleeding or high risk of their development; condition after coronary artery bypass surgery; confirmed hyperkalemia; inflammatory bowel diseases; erosive and ulcerative lesions of the gastrointestinal tract in the acute stage, peptic ulcers; hypocoagulation (including hemophilia); severe renal failure (creatinine clearance less than 30 ml/min); severe hepatic failure or active liver disease; hemorrhagic stroke (confirmed or suspected); hemorrhagic diathesis; impaired hematopoiesis; pregnancy; childbirth; lactation period (breastfeeding); children under 16 years of age (efficacy and safety not established).

Not used as a means for premedication, maintenance anesthesia, analgesia before and during surgical operations (including in obstetric practice) due to the high risk of bleeding.

Not indicated for the treatment of chronic pain.

With caution

Bronchial asthma; cholecystitis; chronic heart failure; arterial hypertension; impaired renal function (plasma creatinine below 50 mg/l); cholestasis; active hepatitis; sepsis; systemic lupus erythematosus; elderly age (over 65 years); polyps of the nasal mucosa and nasopharynx, simultaneous use with other NSAIDs; presence of factors that increase gastrointestinal toxicity: alcoholism, tobacco smoking; postoperative period, edematous syndrome, coronary artery disease, cerebrovascular diseases, dyslipidemia/hyperlipidemia, diabetes mellitus, peripheral arterial diseases, creatinine clearance less than 60 ml/min, history of ulcerative lesions of the gastrointestinal tract, presence of Helicobacter pylori infection, long-term use of NSAIDs, severe somatic diseases, simultaneous use of oral glucocorticosteroids (including prednisolone), anticoagulants (including warfarin), antiplatelet agents (including clopidogrel), selective serotonin reuptake inhibitors (including citalopram, fluoxetine, paroxetine, sertraline).

Use in Pregnancy and Lactation

The use of the drug is contraindicated during pregnancy and during childbirth, during breastfeeding.

Use in Hepatic Impairment

Contraindicated in hepatic failure.

Should be used with caution in cholecystitis, cholestasis, active hepatitis.

Use in Renal Impairment

Contraindicated in renal failure (plasma creatinine >50 mg/l).

Should be used with caution in impaired renal function (plasma creatinine < 50 mg/l).

Pediatric Use

Contraindicated in children and adolescents under 16 years of age (efficacy and safety not established).

Geriatric Use

Should be used with caution in elderly patients (over 65 years of age).

Special Precautions

When used concomitantly with other NSAIDs, fluid retention, decompensation of cardiac activity, and arterial hypertension may be observed.

To reduce the risk of NSAID gastropathy, antacids, misoprostol, omeprazole are prescribed.

The effect on platelet aggregation persists for 24-48 hours.

Hypovolemia increases the risk of adverse reactions from the kidneys.

If necessary, it can be prescribed in combination with opioid analgesics.

Do not use simultaneously with paracetamol for more than 5 days.

In patients with bleeding disorders, use only with constant monitoring of platelet count, especially in the postoperative period, requiring careful monitoring of hemostasis.

Effect on ability to drive vehicles and mechanisms

Since a significant proportion of patients develop side effects from the central nervous system (drowsiness, dizziness, headache) when using ketorolac, it is recommended to avoid work requiring increased attention and quick reactions (driving vehicles, working with mechanisms).

Drug Interactions

Simultaneous use of ketorolac with acetylsalicylic acid or other NSAIDs, calcium preparations, glucocorticosteroids, ethanol, corticotropin may lead to the formation of gastrointestinal ulcers and the development of gastrointestinal bleeding.

Concomitant administration with paracetamol increases nephrotoxicity, with methotrexate – hepato- and nephrotoxicity.

Concomitant administration of ketorolac and methotrexate is possible only when using low doses of the latter (monitor plasma methotrexate concentration).

Against the background of ketorolac use, a decrease in the clearance of methotrexate and lithium and an increase in the toxicity of these substances are possible.

Simultaneous administration with indirect anticoagulants, heparin, thrombolytics, antiplatelet agents, cefoperazone, cefotetan and pentoxifylline increases the risk of bleeding.

Reduces the effect of antihypertensive and diuretic drugs (decreased synthesis of prostaglandins in the kidneys).

With simultaneous use with opioid analgesics, the doses of the latter can be significantly reduced, as their effect is enhanced.

With simultaneous use, it enhances the hypoglycemic effect of insulin and oral hypoglycemic drugs (dose recalculation is necessary).

Concomitant administration with valproic acid causes impaired platelet aggregation.

Increases the plasma concentration of verapamil and nifedipine.

When prescribed with other nephrotoxic drugs (including gold preparations), the risk of nephrotoxicity increases.

Probenecid and drugs that block tubular secretion reduce the clearance of ketorolac and increase its plasma concentration.

Myelotoxic drugs enhance the manifestations of hematotoxicity of ketorolac.

Pharmaceutically incompatible with tramadol solution, lithium preparations.

Storage Conditions

Store at 2°C (36°F) to 25°C (77°F). Keep in original packaging, protected from light. Keep out of reach of children.

Dispensing Status

Rx Only

Important Safety Information

This information is for educational purposes only and does not replace professional medical advice. Always consult your doctor before use. Dosage and side effects may vary. Use only as prescribed.