Analgesics are most effective when given

Myth: Parenteral ketorolac provides more effective analgesia than oral ibuprofen

September 6, 2013 – 11:04

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Medical Mythology

Sanjay Arora, MD;* Jonathan G. Wagner, BA;† Mel Herbert, MD, MB BS, BMedSci‡

*Clinical Instructor of Emergency Medicine and Assistant Residency Director, Keck School of Medicine, Los Angeles County + University of Southern California (LAC+USC) Department of Emergency Medicine, Los Angeles, Calif. †Keck School of Medicine, LAC+USC Department of Emergency Medicine, Los Angeles, Calif. ‡Associate Professor of Medicine, Keck School of Medicine, LAC+USC Department of Emergency Medicine, Los Angeles, Calif.

CJEM 2007;9(1):30-32

Introduction

Acute pain is an extremely common presenting symptom to the emergency department (ED), making it imperative that emergency physicians provide adequate, safe and cost-effective analgesia. Nonsteroidal anti-inflammatory drugs (NSAIDs) are often first-line treatments for moderate to severe pain. Physicians can choose between intramuscular (IM) or intravenous (IV) ketorolac and an oral NSAID. The mechanism of action (reversible inhibition of prostaglandin synthesis at the level of cyclooxygenase) is identical irrespective of the route the medication is given.1 Despite the similar pharmacodynamics, many physicians believe that parenteral ketorolac is more efficacious, despite a greater cost and a more invasive route of administration. To investigate this myth (i.e., that parenteral ketorolac provides greater analgesic effect than an oral NSAID), we conducted a review of the literature, with specific focus on ibuprofen as the prototypical — and least expensive — oral NSAID.

Methods

The terms "ketorolac" and "ibuprofen" were searched in MEDLINE and PubMed, revealing 17 and 67 articles, respectively. Articles were limited to English language and those involving human subjects. All abstracts were reviewed. Articles directly comparing oral ibuprofen with IM or IV ketorolac were included. To ensure no important papers were missed, an ancestral search of identified articles was also performed.

Results

In 1994, Wright and associates evaluated the effectiveness of a single dose of 800 mg of oral ibuprofen (n = 95) versus 60 mg of IM ketorolac (n = 70). This was a retrospective analysis of data collected during a prior prospective survey of pain management efficacy, in patients presenting to the ED with acute pain due to a large variety of causes.2 Using the 100-mm visual analog pain scale (VAS) they found a mean score reduction of 34 in the ibuprofen group and 35 in the ketorolac group. They concluded that the 2 have almost identical efficacy in those presenting with acute pain of varied sources, and that unless oral administration is contraindicated, ibuprofen is superior given its ease of administration, its significantly lower cost, and the lack of pain associated with administration.2

In 1995, Turturro and colleagues compared 800 mg of oral ibuprofen with 60 mg of IM ketorolac in a prospective, double-blind, randomized trial of 82 patients presenting to the ED with acute traumatic musculoskeletal pain.3 They used the 100-mm VAS to quantify pain at baseline, 15, 30, 45, 60, 75, 90 and 120 minutes post dosing. They found no significant differences in mean pain scores at baseline or at any time point throughout the 2-hour period. They noted that the ibuprofen group exhibited lower mean pain scores in the later intervals of the study; however, it was not statistically different. They concluded that oral ibuprofen and IM ketorolac provide similar analgesia with similar onset of action in minor-to-moderate acute musculoskeletal pain and reasoned that IM ketorolac should be reserved for those patients with contraindications to oral intake due to its painful administration and its higher cost (170 times that of ibuprofen at their institution at the time of the study).3

Source: www.cjem-online.ca

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