What is a recommended regimen for in-office treatment using promethazine (Phenergan) and Toradol (ketorolac)?

In-Office Treatment Regimen for Promethazine and Ketorolac

For in-office treatment, administer promethazine 12.5-25 mg IV (infused slowly) with ketorolac 30-60 mg IM for management of pain with associated nausea. 1, 2, 3

Dosing Guidelines

Promethazine Administration

• Intravenous dosing: 12.5-25 mg, infused slowly (maximum rate 25 mg/minute) 1, 2
• When administered IV, use concentration no greater than 25 mg/mL 2
• Preferably inject through tubing of an IV infusion set known to be functioning properly 2
• Consider lower dose (6.25-12.5 mg) for adequate antiemetic effect with less sedation 4
• Duration of action: 4-6 hours with plasma half-life of 9-16 hours 5

Ketorolac Administration

• Standard intramuscular dose: 30-60 mg for acute pain management 3
• Use the lowest effective dose for shortest duration (≤5 days) 3
• Deep intramuscular injection is preferred for administration 3

Clinical Considerations

Patient Monitoring

• Monitor for hypotension, particularly with rapid IV administration of promethazine 5, 1
• Assess for respiratory depression, especially when combining with other sedatives 5
• Observe for extrapyramidal effects ranging from restlessness to oculogyric crises 5
• Monitor for pain during IV injection of promethazine - stop immediately if pain occurs to evaluate for possible arterial injection or extravasation 2

Efficacy

• Low-dose promethazine (6.25 mg IV) has been shown to be as effective as ondansetron 4 mg IV for nausea relief 4
• Ketorolac has demonstrated superior pain relief compared to meperidine-promethazine combinations in some studies 6, 7
• Combination therapy with promethazine and other agents has shown improved efficacy for nausea control 8

Safety Precautions

Promethazine Warnings

• Never administer promethazine by intra-arterial injection due to risk of severe arteriospasm and gangrene 2
• Subcutaneous injection is contraindicated as it may result in tissue necrosis 2
• Stop infusion immediately if patient complains of pain during IV administration 2
• Avoid rapid administration to minimize hypotension risk 5, 1

Ketorolac Warnings

• Total combined duration of ketorolac use should not exceed 5 days 3
• Contraindicated in patients with advanced renal impairment or risk of renal failure 3
• Use caution in elderly patients - consider reduced dosing 3

Special Populations

Elderly Patients

• Consider reduced dosing for both medications in elderly patients 2, 3
• For promethazine, start with 12.5 mg IV in elderly patients 1
• For ketorolac, consider half-dose in patients over 65 years 6

Pediatric Patients

• Promethazine is contraindicated in children younger than 2 years 1, 2
• Use caution when administering promethazine to pediatric patients 2 years and older 2

Combination Therapy Considerations

• When using promethazine as an adjunct to pain management, the dose of analgesics may need to be reduced 5, 1
• The combination of ketorolac with promethazine provides both analgesic and antiemetic effects 6
• Promethazine may enhance the sedative effects of opioids and other CNS depressants 5, 1

Practical Administration Tips

• Inspect solutions visually for particulate matter and discoloration prior to administration 2
• Do not use promethazine if solution has developed color or contains precipitate 2
• Consult specialized literature before diluting with any injectable solution or combining with other medications 2