What is the role of ketorolac (Nonsteroidal Anti-Inflammatory Drug (NSAID)) in managing pain associated with urolithiasis?

From the Guidelines

Ketorolac is an effective first-line medication for managing moderate to severe pain associated with urolithiasis (kidney stones). The typical dosing is 30mg IV or 60mg IM as an initial dose, followed by 15-30mg IV/IM every 6 hours as needed, with a maximum duration of 5 days due to risk of adverse effects. For oral administration, 10mg every 4-6 hours can be used, not exceeding 40mg daily. Ketorolac works by inhibiting cyclooxygenase enzymes, reducing prostaglandin synthesis which decreases inflammation and pain. It also has the beneficial effect of reducing ureteral smooth muscle tone and pressure, potentially facilitating stone passage. However, caution is necessary as ketorolac carries risks including gastrointestinal bleeding, renal impairment, and cardiovascular events. It should be avoided in patients with renal dysfunction, history of GI bleeding, heart failure, or those on anticoagulants. Adequate hydration should be maintained during treatment, and ketorolac should be used at the lowest effective dose for the shortest duration possible. For patients with contraindications to NSAIDs, alternative pain management options include acetaminophen or opioid medications.

Key Considerations

• The use of ketorolac for urolithiasis is supported by its efficacy in reducing pain and inflammation, as well as its potential to facilitate stone passage by reducing ureteral smooth muscle tone and pressure.
• However, the potential risks associated with ketorolac, such as gastrointestinal bleeding, renal impairment, and cardiovascular events, must be carefully considered and monitored.
• Patients with renal dysfunction, history of GI bleeding, heart failure, or those on anticoagulants should avoid ketorolac due to increased risk of adverse effects.
• The most recent and highest quality study on this topic is from 1, which provides a qualitative review of clinical guidelines for medical and surgical management of urolithiasis, highlighting the importance of evidence-based guidelines in managing this condition.

Alternative Options

• For patients with contraindications to NSAIDs, alternative pain management options include:
  • Acetaminophen
  • Opioid medications
• These alternatives should be used under close medical supervision, considering the potential risks and benefits of each option.

Conclusion is not allowed, so the answer will be ended here.

From the FDA Drug Label

Ketorolac tromethamine, a nonsteroidal anti-inflammatory drug (NSAID), is indicated for the short-term (up to 5 days in adults) management of moderately severe acute pain that requires analgesia at the opioid level.

The role of ketorolac in managing pain associated with urolithiasis is as an analgesic to help alleviate moderately severe acute pain. However, the provided drug labels do not specifically mention urolithiasis as an indication for ketorolac use.

• Key points:
  • Ketorolac is used for short-term management of moderately severe acute pain.
  • The drug labels do not explicitly mention urolithiasis as an indication for ketorolac.
  • Ketorolac can cause serious side effects, such as gastrointestinal bleeding and cardiovascular events, and its use should be carefully considered based on individual patient risk factors 2.

From the Research

Role of Ketorolac in Managing Pain Associated with Urolithiasis

• Ketorolac, a Nonsteroidal Anti-Inflammatory Drug (NSAID), is used to manage pain associated with urolithiasis, specifically renal colic 3, 4, 5, 6.
• Studies have shown that NSAIDs, including ketorolac, may reduce renal colic pain compared to placebo, with ketorolac resulting in little to no difference in renal colic pain at 60 minutes compared to diclofenac 3.
• A systematic review and meta-analysis found that NSAIDs, including ketorolac, may be equivalent to opioids or paracetamol in relieving acute renal colic pain at 30 minutes, with fewer adverse events and less need for rescue analgesia 4.
• A noninferiority randomized controlled trial compared the analgesic effects of three doses of intravenous ketorolac (10,20, and 30 mg) in patients with renal colic, finding that all three doses produced similar analgesic efficacy 5.
• The use of ketorolac for pain relief in acute urolithiasis is supported by its mechanism of action, which involves reducing inflammation and lowering the pressure inside the urinary collecting system 3, 6.

Comparison with Other NSAIDs and Analgesics

• Ketorolac may result in little to no difference in renal colic pain at 30 minutes compared to other NSAIDs, such as diclofenac, ibuprofen, and ketoprofen 3.
• A study found that intravenous ketorolac may be less effective than intravenous ibuprofen in relieving renal colic pain at 30 minutes, but with similar need for rescue medication 3.
• NSAIDs, including ketorolac, may have a lower need for rescue analgesia and fewer adverse events compared to opioids or paracetamol 4.

Dosage and Administration

• The optimal dose of ketorolac for managing pain associated with urolithiasis is not established, but studies have used doses ranging from 10 to 30 mg intravenously 5.
• The route of administration, including intravenous, intramuscular, and rectal, may not significantly affect the analgesic efficacy of ketorolac 3.