July 21, 2020

Safety of parenteral ketorolac use for analgesia in geriatric emergency department patients

By ejschwartz

Caitlin Brown, PharmD and Alicia Mattson, PharmD

Dr. Brown and Dr. Mattson are pharmacists at Mayo Clinic in the Emergency Department.

With the rapidly increasing population of individuals aged 65 years and older, pain management in the emergency department (ED) has become much more complex. Many of the medications we use to treat pain in the ED are on the American Geriatrics Society Beers Criteria, including nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids. According to this list there is a strong recommendation to avoid ketorolac; however, there is no guidance on whether a single dose is acceptable and safe. In order to find safe ways to treat pain in our geriatric patients we assessed whether a single dose of ketorolac in the ED contributed to adverse cardiovascular, gastrointestinal, and renal outcomes.

This was a single-center retrospective study including patients 65 years of age and older who received intramuscular or intravenous ketorolac for analgesia management prior to being discharged home. We directly matched patients 3:1 who did not receive ketorolac. The primary outcome was the occurrence of any of the following events within 30 days of the ED visit: gastrointestinal bleeding, intracranial bleeding, acute decompensated heart failure, acute coronary syndrome, dialysis, transfusion, and death. The secondary outcome was the occurrence of an increase in serum creatinine of ≥1.5 times baseline within 7 and 30 days of the ED visit.

We found the primary outcome occurred in 14 of 360 patients who did not receive ketorolac and 2 of 120 patients who received parental ketorolac (3.9% vs 1.7%, p=0.38; OR 2.39, 95% CI 0.54-10.66). Both events in the ketorolac group were GI bleeds. We also did not find a significant number of patients with an increase in serum creatinine who received ketorolac.

 This study found one time doses of ketorolac to be safe in low-risk geriatric patients. Given this study’s retrospective design, there is risk for selection bias. The patients in this study, although advanced in age, are likely low risk. Ketorolac can be considered for analgesia in the emergency department to help limit exposure to opioids and suboptimal pain management.

Check out our full study in the American Journal of Emergency Medicine for more information!

https://www.sciencedirect.com/science/article/pii/S0735675719303869

Find the authors on Twitter:

@CBthePharmD

@AM_EM_PharmD

@CabreraERDR

@mfbellolio

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