Is ketorolac (Nonsteroidal Anti-Inflammatory Drug (NSAID)) less effective than other NSAIDs?

From the Guidelines

Ketorolac is not less effective than other NSAIDs; in fact, it is considered one of the most potent NSAIDs available for acute pain management. Ketorolac (typically dosed at 10-30mg IV/IM or 10mg orally) provides analgesic efficacy comparable to low-dose opioids, making it particularly valuable in emergency and postoperative settings 1. However, its use is limited to short durations, generally not exceeding 5 days, due to increased risk of serious adverse effects with prolonged use. Ketorolac works by inhibiting both COX-1 and COX-2 enzymes, thereby reducing prostaglandin synthesis and providing potent anti-inflammatory and analgesic effects. It differs from many other NSAIDs in its particularly strong analgesic properties and parenteral formulation options. Important limitations include contraindications in patients with renal impairment, active peptic ulcer disease, history of GI bleeding, and those at high risk for bleeding. Ketorolac should also be used cautiously in elderly patients and those with cardiovascular disease. When appropriate for short-term acute pain management, ketorolac offers significant advantages in providing non-opioid analgesia with potency that exceeds most other NSAIDs.

Some key points to consider when using ketorolac include:

• Its potent analgesic effects, which are comparable to low-dose opioids 1
• The need for short-term use, typically not exceeding 5 days, due to increased risk of adverse effects with prolonged use 1
• Contraindications in patients with renal impairment, active peptic ulcer disease, history of GI bleeding, and those at high risk for bleeding 2
• The importance of cautious use in elderly patients and those with cardiovascular disease 3
• The potential for increased GI risk, particularly with prolonged use or in patients with a history of GI complications 3, 4

Overall, ketorolac is a valuable option for acute pain management, particularly in emergency and postoperative settings, due to its potent analgesic effects and parenteral formulation options. However, its use must be carefully considered and monitored due to the potential for adverse effects.

From the Research

Efficacy of Ketorolac Compared to Other NSAIDs

• Ketorolac has been shown to have similar analgesic efficacy to other NSAIDs, such as ibuprofen and acetaminophen with codeine 5.
• In some studies, ketorolac has been found to be as effective as morphine and pethidine in treating moderate to severe pain 6, 7, 8.
• However, ketorolac may have a slower onset of action compared to opioids, which can limit its utility in acute pain management 5.

Comparison of Ketorolac to Other Analgesics

• Ketorolac has been compared to aspirin, paracetamol, and other non-steroidal anti-inflammatory drugs, and has been found to have greater efficacy in some cases 7.
• In a study comparing intravenous ketorolac to morphine, ketorolac was found to have similar analgesic efficacy to morphine, but with a more favorable adverse effect profile 8.
• A randomized controlled trial found that intravenous ketorolac at doses of 10, 15, and 30 mg had similar analgesic efficacy in treating acute pain in the emergency department 9.

Limitations and Adverse Effects

• Ketorolac has a tolerability profile similar to other NSAIDs, with most clinically important adverse events affecting the gastrointestinal tract and/or renal or haematological function 6.
• The incidence of serious or fatal adverse events reported with ketorolac has decreased since revision of dosage guidelines 6.
• High doses of ketorolac for extended periods can increase the risk of gastrointestinal or operative site bleeding, particularly in the elderly 6.