We Can Treat Pain- Even Without Ketorolac
ABSTRACT & COMMENTARY
Source: Neighbor ML, Puntillo KA. Intramuscular ketorolac vs. oral ibuprofen in emergency department patients with acute pain. Acad Emerg Med 1998;5:118-122.
Ketorolac, the first fda-approved parenteral nonsteroidal antiinflammatory drug, has gained widespread popularity and use in the ED management of pain. Neighbor and Puntillo sought to compare intramuscular ketorolac to oral ibuprofen in a double-blind, randomized, prospective, convenience sample study of adult patients with moderate-to-severe pain. Patients rating their pain between 5 and 8 on a 10-point numeric rating scale (NRS) were eligible for randomization to receive either 60 mg ketorolac IM and a placebo capsule, or a placebo (saline) IM injection and an 800 mg ibuprofen capsule. Subsequent NRS pain ratings were obtained at 15, 30, 45, 60, 90, and 120 minutes post-treatment. Sixty-one patients were randomized to receive IM ketorolac, whereas 58 patients received oral ibuprofen. There was no significant difference between the two groups in gender, age, ethnicity, or pretreatment pain score. Both groups reported significant decreases in pain over time, but there was no difference between groups over time or at any study point prior to completion of evaluation. In addition, at the end of the two-hour study period, a full 40% of patients still reported pain in the moderate-to-severe range (NRS 5-8). Neighbor and Puntillo conclude that there is no difference between IM ketorolac and oral ibuprofen (at the doses studied) in the treatment of patients with moderate-to-severe pain.
COMMENT BY FREDERIC H. KAUFFMAN, MD
The above study did indeed demonstrate that both IM ketorolac and oral ibuprofen produced significant reductions in pain in their study population, as demonstrated by an overall decrease in NRS of 46% (from 6.8 to 3.7 and from 7.0 to 3.8 in the two groups, respectively). More importantly, however, at two hours post-treatment, 40% of patients remained in the moderate-to-severe pain range. The latter fact speaks to the problem of under- treatment of pain in the ED, especially since supplemental analgesia was permitted in both study groups as deemed necessary by the treating physicians. I applaud the investigators for evaluating the expensive parenteral medication (ketorolac) vs. the inexpensive oral medication (ibuprofen). The lack of difference in pain relief between the two groups further supports my contention that the ketorolac bandwagon is much too large and rarely worth the cost.
I make these final points regarding pain management in the ED: 1) patients with moderate-to-severe pain deserve intravenous analgesics; 2) parenteral ketorolac should be largely reserved for the management of renal and biliary colic; 3) under-treatment of pain is the main issue to address-not necessarily which analgesic to use; and 4) successful and safe pain management was possible even before the advent of ketorolac.
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