Ketral

Ketral

ketorolac

Manufacturer:

Oboi

Distributor:

Phil Pharmawealth
Full Prescribing Info
Contents
Ketorolac tromethamine.
Description
Each mL contains: Ketorolac trometamol 30 mg.
Action
Pharmacology: Mechanism of Actions: Ketorolac tromethamine is a non-narcotic analgesic. It inhibits synthesis of prostaglandins and is considered a peripherally acting analgesic since it does not have any known effects on opiate receptors. No evidence of respiratory depression has been observed after administration of Ketorolac tromethamine. It did not cause pupil constriction. It caused no more drowsiness than placebo and less drowsiness than morphine in post-operative patients. It is non-steroidal anti-inflammatory agent that exhibits anti-inflammatory and antipyretic activity.
Pharmacokinetics: Ketorolac tromethamine is rapidly and completely absorbed following intramuscular administration with a mean peak plasma concentration of 2.2 mcg/mL occurring an average of 50 minutes after a single 30 mg dose. The terminal plasma half-life is 5.3 hours in young adults and 7 hours in elderly subjects (mean age 72). Intravenous administration of a single 10 mg dose of ketorolac tromethamine results in a terminal plasma elimination half-life of 5.1 hours, an average volume of distribution of 0.15 L/kg and a total plasma clearance of 0.35 mL/min/kg. More than 99% of the ketorolac in plasma is protein-bound over a wide concentration range. The pharmacokinetics of ketorolac in man following single or multiple intramuscular (IM) doses are linear. Steady-state plasma levels are achieved after dosing every 6 hours of 1 day. No changes in clearance occur with chronic dosing. The primary route of excretion of ketorolac and its metabolites (conjugates and a para-hydroxyl metabolite) is in the urine (mean 91.4%) and the remainder (mean 6.1%) is excreted in the feces. See table.

Click on icon to see table/diagram/image

Haemodynamics of patients are not altered by parenteral administration of Ketorolac tromethamine.
Indications/Uses
For short term management of moderate to severe acute post-operative pain following surgical procedures associated with low risk haemorrhage.
Dosage/Direction for Use
Dosage should be adjusted according to the severity of the pain and the patient response. The recommended usual initial dose of ketorolac tromethamine is 30 mg followed by 10-30 mg every 4-6 hours as needed to control pain. A lower initial dose is recommended for patients under 50 kg, for patients over 65 years and for patients with reduced renal function. In the initial postoperative period, ketorolac tromethamine may be given as often as every 2 hours if needed. A total daily dose >120 mg/day is not recommended. Intravenous injections should be administered over at least 15 seconds.
Opiate analgesic (eg, morphine, pethidine) may be concomitantly used if further pain relief, anxiolytic effects and/or sedative effects of opiates are desired. Supplemented opiates may be most appropriate in the early postoperative period when pain is most severe. The administration of continuous multiple day IM doses of ketorolac tromethamine should not exceed 2 days because adverse events may increase with prolonged usage.
Contraindications
Ketorolac tromethamine should not be used: In patients who have previously exhibited allergy to it; in suspected or confirmed cerebrovascular bleeding or haemophilia in other bleeding problems including coagulation or platelet function disorders due to increased risk of bleeding because ketorolac inhibits platelet aggregation and may also cause gastrointestinal ulceration or haemorrhage; in active, recent or history of gastrointestinal bleeding or recent gastrointestinal perforation or active or history of peptic ulceration, ulceration colitis or other ulcerative gastrointestinal disease due to increased risk of gastrointestinal ulceration, perforation and/or haemorrhage; in aspirin induced nasal polyps associated with bronchospasm, or angioedema, anaphylaxis or history of other severe allergic reactions of cross-sensitivity; in severe renal function impairment due to increased risk of renal failure; during pregnancy labour, delivery or lactation; a history of asthma; hypovolaemia or dehydration from any cause.
Ketorolac tromethamine is not an anaesthetic agent and possesses no sedative or anxiolytic properties; therefore it is not recommended as a preoperative medication when these effects are required.
Ketorolac is not recommended in obstetric analgesia.
Carcinogenicity, mutagenicity and impairment of fertility: In animal, Ketorolac was not associated with tumourigenecity or mutagenicity and did not demonstrate teratogenic potential.
Use in pregnancy and lactation: Ketorolac tromethamine is not recommended during pregnancy; labor or delivery. Ketorolac tromethamine is not recommended for treatment of nursing mothers. Secretion of ketorolac in human milk after ingestion of ketorolac tromethamine is limited. The milk to plasma ration of ketorolac concentrations ranged between 0.015 and 0.037.
Use in children: Safety and efficacy in children have not been established. Therefore, it is not recommended for use in children under 16 years.
Use in the elderly: Because ketorolac is cleared somewhat more slowly by the elderly (see Pharmacology under Actions), who are also more sensitive to the renal effects of NSAIDs (see Renal effects under Precautions), extra caution and the lowest effective dose should be when treating the elderly with ketorolac tromethamine.
Drug abuse and physical dependence: Ketorolac is not a narcotic agonist or antagonist. No subjective symptoms or objective signs of drug withdrawal upon abrupt discontinuation of IV or IM dosing. Patients receiving ketorolac tromethamine for 6 months or longer have not developed which are reasonable predictors of opiate analgesic action (hot plate and tail withdrawal test). In vitro, ketorolac dose not bind to opiate receptors.
These demonstrate that ketorolac tromethamine does not have central opiate-like activity.
Warnings
Risk of GI ulceration, bleeding and perforation with NSAID: Serious GI toxicity such as bleeding, ulceration ad perforation can occur at any time, with or without warning symptoms, in patients treated with NSAID therapy. Although minor upper GI problems (eg, dyspepsia) are common, usually developing early in therapy, prescribers should remain alert for ulceration and bleeding in patients treated with NSAID even in the absence of previous GI tract symptoms.
Studies to date have not identified any subset of patients not at risk of developing peptic ulceration and bleeding. Patients with prior history of serious adverse events and other risk factors associated with peptic ulcer disease (eg, alcoholism, smoking, and corticosteroid therapy) are at spontaneous reports for fatal GI events.
Special Precautions
As with other non-steroidal anti-inflammatory analgesic agents, ketorolac tromethamine can cause gastrointestinal irritation, ulcers or bleeding with or without previous symptoms and should be given under close supervision to patients with a history of gastrointestinal tract disease. Elderly and debilitated individuals are most susceptible to these complications, the incidence of which increased with dose and duration of treatment.
Renal effects: As with other non-steroidal anti-inflammatory drugs that inhibits prostaglandin biosynthesis, elevations of serum urea nitrogen and creatinine have been reported with ketorolac tromethamine. Since ketorolac tromethamine and its metabolites are excreted primarily by the kidney, patients with significant impairment or renal functions should not receive ketorolac tromethamine unless the expected benefits outweigh the risks. If used in patients with impaired renal function, ketorolac tromethamine dosage should be reduced and renal status should be closely monitored. In patients with serum creatinine values ranging from 1.9-5 mg/dL, the rate of ketorolac clearance was reduced to approximately half of normal. The total daily dose of ketorolac should be reduced by half in such patients. With more severe degrees of renal impairment, ketorolac is not recommended for patients with serum creatinine levels above 5 mg/dL. Patients who are volume-depleted because of blood loss or severe dehydration may be dependent on renal prostaglandin production to maintain renal perfusion and therefore, glomerular fibrillation rate. In such situations, the use of drugs which inhibits prostaglandin synthesis might be expected to further decrease renal blood flow. Caution is advised if ketorolac tromethamine is used in such circumstances. Close monitoring of urine output, serum urea and serum creatinine is recommended until the patient is normo-volemic. As with other drugs that inhibit prostaglandin biosynthesis, the following renal abnormalities may be associated with the use of ketorolac tromethamine. Glomerular nephritis, interstitial nephritis, renal papillary necrosis, nephrotic syndrome and acute renal failure.
Other renal disease is possible.
Fluid retention and oedema: Fluid retention and oedema have been reported with use of ketorolac tromethamine, therefore, ketorolac tromethamine should be used with caution in patients with cardiac decompensation, hypertension or similar conditions.
Haematologic Effects: Ketorolac tromethamine inhibits platelet aggregation and may prolong bleeding time. Patients on full anticoagulation therapy (eg, heparin or dicumarol derivatives) may be at increased risk of bleeding if given ketorolac tromethamine concurrently. Thus, the benefits should be weighed against the risk. Low-dose heparin (5000 units SC 2 times a day) appears to be associated with less risk. Patients who have coagulation disorders or are receiving drug therapy that interferes with haemostasis should carefully observed if ketorolac tromethamine is administered.
Unlike the prolonged effects from aspirin, the inhibition of platelet function by ketorolac disappears within 24-48 hours after the drug is discontinued.
Ketorolac does not affect platelet count, prothrombin time (PT) or partial thromboplastin time (PTT). Where ketorolac was administered postoperatively, the incidence of significant postoperative bleeding was similar to control group ie, 5/1170 (0.4%) with ketorolac tromethamine compared to 1/570 (0.2%) with opiates. Postoperative wound hemorrhage has been reported rarely in association with the immediate perioperative use of ketorolac tromethamine. Therefore, caution should be used where strict haemostasis is critical. Specifically in cosmetic plastic surgery, haematomas and other signs of wound hemorrhage have been reported with the use of ketorolac tromethamine. Physicians should be alert to the pharmacologic similarity of ketorolac to other non-steroidal anti-inflammatory drugs that inhibits cyclooxygenase.
Hepatic effects: Borderline elevation of one or more liver tests may occur. These abnormalities may progress, may remain unchanged or may be transient with continued therapy. Meaningful elevations (>3 times normal) of serum glutamic oxaloacetic transaminase (SGOT or AST) occurred in <1% of patients. If clinical signs and symptoms consistent with liver disease develop or if systemic manifestation occur (eg, eosinophila, rash, etc), ketorolac tromethamine should be discontinued. Patients with impaired hepatic functions from cirrhosis do not have any clinically important changes in ketorolac clearance.
Adverse Reactions
The following adverse reactions were reported to be probably related to ketorolac tromethamine in patients which received up to 20 doses in up to 5 days of IM administered ketorolac tromethamine 30 mg and in patients which received up to 8 doses in 2 days of IV administered ketorolac tromethamine 30 mg.
Incidence between 3 and 9%: Gastrointestinal: Nausea, dyspepsia, gastrointestinal pain.
Central nervous system: Drowsiness.
Incidence between 1 and 3%: Gastrointestinal: Diarrhoea.
Central Nervous system: Dizziness, headache, sweating.
Body as a whole: Edema.
Injection site pain was reported by 2% of patient.
Incidence 1% or less: Gastrointestinal: Constipation, flatulence, gastrointestinal fullness, liver function abnormalities, melena, peptic ulcer, rectal bleeding, stomatitis, vomiting.
Body as a whole: Asthenia, myalgia.
Cardiovascular: Flushing, pallor.
Hemic and lymphatic: Purpura.
Nervous system: Dry mouth, nervousness, paraesthesia, abnormal thinking, depression, euphoria, excessive thirst, inability to concentrate, insomnia, stimulation, vertigo.
Respiratory: Dyspnea, asthma.
Urogenital: Increased urinary frequency, oliguria.
Dermatologic: Pruritus, urticaria.
Special senses: Abnormal taste, abnormal vision.
Drug Interactions
Given 10 mg orally for 6 days prior to co-administration of a single dose of warfarin 25 mg, no significant changes in pharmacokinetics of the warfarin enantiomers were detected. Ketorolac is highly bound to plasma proteins (mean 99.2%) and binding is independent of concentration. The in vitro binding of warfarin to plasma proteins is only slightly reduced by ketorolac. Ketorolac does not alter digoxin, protein binding. In vitro at therapeutic concentrations of salicylate (300 mcg/mL). The binding of ketorolac was reduced from approximately 99.2%-97.5%. Therapeutic concentrations of digoxin, warfarin, acetaminophen, phenytoin and tolbutamide did not alter ketorolac protein binding. Because ketorolac is a highly potent drug and present in low concentrations in plasma, it would be expected to displace other protein-bound drugs significantly.
There is no evidence that ketorolac induces or inhibits the hepatic enzymes capable of metabolizing itself or other drugs. Hence ketorolac would not be expected to alter the pharmacokinetics of other drugs due to enzyme induction of inhibition mechanisms.
Concomitant administration of ketorolac tromethamine and probenecid results in the decreased clearance of ketorolac and a significant increase in ketorolac plasma levels and terminal half-life of ketorolac.
Ketorolac tromethamine reduces the diuretic response to furosemide in normo-volemic healthy subjects by approximately 20%. Inhibition of renal lithium clearance leading to an increase in plasma lithium concentrations and potential lithium toxicity has been reported with some prostaglandin synthesis inhibiting drugs. Concomitant administration of ketorolac tromethamine and methotrexate, and thus possibly enhance the toxicity of methotrexate. Ketorolac tromethamine has been administered concurrently with morphine in postoperative pain without evidence of adverse interactions. There are no clinical data available dealing with the safety or efficacy of concomitant use with other non-steroidal anti-inflammatory drugs. It is not recommended that ketorolac tromethamine be routinely used with other non-steroidal anti-inflammatory drugs because of potential for additive side effects.
Caution For Usage
Incompatibilities: This product should not be mixed in a small volume (eg, in a syringe) with morphine sulphate, pethidine HCl, promethazine HCl or hydroxyzine HCl as precipitation of ketorolac tromethamine will occur. It is compatible with normal saline, 5% dextrose, Ringer's solution, Ringer's lactate solution or plasmalyte solution.
Storage
Store at temperatures not exceeding 30°C. Protect from light.
ATC Classification
M01AB15 - ketorolac ; Belongs to the class of acetic acid derivatives and related substances of non-steroidal antiinflammatory and antirheumatic products.
Presentation/Packing
Soln for inj (amp; clear, faintly yellow liquid) 30 mg/mL x 1 mL x 10's.
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