What is the appropriate management for an 88-year-old woman presenting to primary care with a muscle strain in the right lower rib cage, treated with 30 milligrams of Toradol (Ketorolac) intramuscularly (IM)?

From the Guidelines

The administration of 30 mg of Toradol (ketorolac) IM to an 88-year-old woman presenting with muscle strain in the right lower rib cage is not recommended due to the increased risk of adverse effects in elderly patients, and instead, a regular administration of intravenous acetaminophen every 6 h as first line treatment should be considered. For elderly patients, the use of NSAIDs like ketorolac should be cautious, taking into account potential adverse events and pharmacological interactions 1. The maximum daily dose of ketorolac should not exceed 60 mg, and treatment duration should be limited to a maximum of 5 days. Before administration, assess renal function as ketorolac is contraindicated in patients with advanced renal impairment and carries risk in those with moderate impairment. Also, evaluate for other contraindications including history of GI bleeding, stroke risk, heart failure, or concurrent use of anticoagulants. Consider alternative pain management options such as acetaminophen (up to 3000 mg daily in divided doses) or topical analgesics. If Toradol is administered, monitor for signs of GI bleeding, changes in renal function, and cardiovascular events. This caution is warranted because NSAIDs like ketorolac carry significantly higher risks in elderly patients, including acute kidney injury, gastrointestinal bleeding, and cardiovascular complications, with these risks increasing substantially with age.

Some key points to consider in the management of acute pain in elderly patients include:

• The use of a multimodal analgesic approach, including acetaminophen, gabapentinoids, NSAIDs, lidocaine patches, and opioids only for breakthrough pain for the shortest period of administration at the lowest effective dose 1.
• The implementation of non-pharmacological measures such as immobilizing limbs and applying dressings or ice packs in conjunction with drug therapy, in control acute pain in elderly patients in the trauma setting 1.
• The careful evaluation of the use of neuraxial and plexus blocks for patients receiving anticoagulants to avoid bleeding and complications 1.
• The consideration of the patient's clinical features, such as renal function, history of GI bleeding, and concurrent use of anticoagulants, when selecting analgesics 1.
• The use of pain assessment tools, such as the numeric rating scale (NRS), verbal descriptor scale (VDS), faces pain scale (FPS), and visual analogue scale (VAS), to quantify pain intensity 1.

In the context of this patient, a more appropriate management approach would be to start with a regular administration of intravenous acetaminophen every 6 h, and consider adding other analgesics, such as gabapentinoids or lidocaine patches, as needed, while closely monitoring for signs of adverse effects. This approach is supported by the 2023 WSES guidelines on the management of trauma in elderly and frail patients, which recommend a multimodal analgesic approach, including acetaminophen, gabapentinoids, NSAIDs, lidocaine patches, and opioids only for breakthrough pain for the shortest period of administration at the lowest effective dose 1.

From the FDA Drug Label

KETOROLAC TROMETHAMINE INJECTION Ketorolac tromethamine injection may be used as a single or multiple dose on a regular or “prn” schedule for the management of moderately severe, acute pain that requires analgesia at the opioid level, usually in a postoperative setting. Single-Dose Treatment: The following regimen should be limited to single administration use only Intramuscular Dosing Patients <65 years of age: One dose of 60 mg Patients ≥65 years of age, renally impaired and/or less than 50 kg (110 lbs) of body weight: One dose of 30 mg.

The patient was given a single dose of 30 mg of Toradol (Ketorolac) intramuscularly (IM), which is the recommended dose for patients ≥65 years of age, renally impaired, and/or less than 50 kg (110 lbs) of body weight.

• The duration of analgesic effect is usually 4 to 6 hours.
• For breakthrough pain, consider supplementing with low doses of opioids “prn” unless otherwise contraindicated.
• Ketorolac tromethamine therapy is not to exceed 5 days 2 2.

From the Research

Management of Muscle Strain

• The patient's condition, an 88-year-old woman with a muscle strain in the right lower rib cage, can be managed with rest, ice, compression, and nonsteroidal anti-inflammatory drug therapy, as suggested by 3.
• The use of Toradol (Ketorolac) intramuscularly (IM) at a dose of 30 milligrams is consistent with its analgesic efficacy for acute pain, as reported in 4 and 5.
• However, it is essential to consider the potential risks and adverse events associated with ketorolac, particularly in elderly patients, as noted in 4 and 5.
• The patient's age and potential comorbidities should be taken into account when managing her condition, and alternative therapies, such as topical analgesics, may be considered, as discussed in 6.

Considerations for Ketorolac Use

• Ketorolac has a delayed onset of action, which may limit its utility in acute pain management, as mentioned in 4.
• The drug's analgesic efficacy may be enhanced when used in combination with other therapies, such as opioids, as reported in 5.
• The risk of adverse events, including gastrointestinal and renal complications, should be carefully monitored, particularly in elderly patients, as noted in 5.

Alternative Therapies

• Topical analgesics, such as diclofenac and ketoprofen, may be effective in managing acute musculoskeletal pain, as discussed in 6.
• These therapies may be considered as an alternative or adjunct to ketorolac, particularly in patients who are at risk of adverse events or have contraindications to NSAID use.