C=15 | H=13 | N=1 | O=3
molecular_weight =376.4 g/mol
bioavailability = 100% (All routes)
metabolism = Hepatic
elimination_half-life =3.5-9.2 hrs, young adults;
4.7-8.6 hrs, elderly (mean age 72)
excretion = Renal:91.4% (mean)
pregnancy_AU = C
pregnancy_US = C
legal_status = Rx-only
routes_of_administration = oral, I.M., I.V.
Ketorolac or ketorolac tromethamine (marketed under the trademarks Toradol and Acular in the US, where generics have also been approved, and various other brand names around the world) is a
non-steroidal anti-inflammatory drug(NSAID) in the family of heterocyclic acetic acidderivatives, often used as an analgesic, antipyretic( feverreducer), and anti-inflammatory. Ketorolac acts by inhibiting the bodily synthesis of prostaglandins. Ketorolac in its oral ( tabletor capsule) and intramuscular (injected) preparations is a racemic mixtureof both ("S")-(−)-ketorolac, the active isomer, and ("R")-(+)-ketorolac. An ophthalmic (i.e., eye-drop) solution of ketorolac is available and is used to treat eye pain and to relieve the itchiness and burning of seasonal allergies.
Ketorolac, like other 2-aryl
propionatederivatives (including ketoprofen, flurbiprofen, naproxen, ibuprofen, etc.) contains a chiral carbonin the α-position of the propionate moiety. As such, there are two possible enantiomers of ketorolac with the potential for different biological effects and metabolismfor each enantiomer.
NSAIDs are not recommended for use with other NSAIDs because of the potential for additive side effects.
The protein-binding effect of most non-
aspirinNSAIDs is inhibited by the presence of aspirin in the blood.
Mechanism of action
mechanism of actionresponsible for ketorolac's anti-inflammatory, antipyretic and analgesic effects is the inhibition of prostaglandin synthesis by competitive blocking of the the enzyme cyclooxygenase(COX). Like most NSAIDs, ketorolac is a non-selective COX inhibitor.
As with other
NSAIDs, the mechanism of the drug is associated with the chiral S form. Conversion of the R enantiomer into the S enantiomer has been shown to occur in the metabolismof ibuprofen; it is unknown whether it occurs in the metabolism of ketorolac.
Ketorolac is indicated for short-term management of pain (up to five days maximum).
Ketorolac is contraindicated in patients with a previously demonstrated
hypersensitivityto ketorolac, and in patients with the complete or partial syndromeof nasal polyps, angioedema, bronchospastic reactivity or other allergic manifestations to aspirin or other non- steroidal anti-inflammatory drugs (due to possibility of severe anaphylaxis). As with all NSAIDs, ketorolac should be avoided in patients with renal ( kidney) dysfunction. (Prostaglandins are needed to dilate the afferent arteriole; NSAIDs effectively reverse this.) The patients at highest risk, especially in the elderly, are those with fluid imbalances or with compromised renal function (e.g., heart failure, diureticuse, cirrhosis, dehydration, and renal insufficiency).
Similar to other NSAIDs. "See inset "Ketorolac adverse effects."
Warnings and precautions
The most serious risks associated with ketorolac are, as with other NSAIDs, gastrointestinal
ulcers, bleeding and perforation; renal ( kidney) events ranging from interstitial nephritisto complete kidney failure; hemorrhage, and hypersensitivity reactions.
As with other NSAIDs, fluid and solute retention and
edemahave been reported with ketorolac. Ketorolac also elevates liver protein levels.
It should be noted that when administered intravenously through the same IV
catheteras morphine, the two drugs have been known to sometimes combine to form a precipitate in the IV, which may block the line. Line flushing with a syringeof saline solutioncan push the blockage through.
Ketorolac is not recommended for pre-operative analgesia or co-administration with
anesthesiabecause it inhibits plateletaggregation and thus may be associated with an increased risk of bleeding.
Ketorolac is not recommended for long-term
However, ketorolac has been co-administered with
meperidineand morphine without apparent adverse effects on patients.
Dosage, availability and cost
Oral dosage is 10 mg; United States price for 20 tablets hovers around US$28. Australian pricing for 20 tablets is around AU$44.cite web | url = http://www.epharmacy.com.au/searchresults.asp?searchsection=products&terms=toradol&stype=NP&expand=0 | title = Search for Toradol | publisher = ePharmacy | accessdate = 2007-10-16] It is considerably less expensive in
Mexico(where it is called "ketorolaco", and marketed under various brand names, such as Glicima, from Atlantis Pharma, and Supradol, from Laboratorios Liamont).
Injected dosages are 15, 30 and 60 mg; US price for 10 vials of 30 mg each is around US$45, making the preparation considerably more expensive per dose. One 60-mg dose would require the administration by injection of two vials, at about $9 per dose. Australian pricing for 5 vials is around AU$58, or about $23 per dose. Ketorolac is not available on the
Pharmaceutical Benefits Scheme. [cite web | url = http://www.pbs.gov.au/html/consumer/search/results?medicine=ketorolac | title = Search for Ketorolac | publisher = Pharmaceutical Benefits Scheme | accessdate = 2007-10-16]
In the United States, [cite web | url = http://redpoll.pharmacy.ualberta.ca/drugbank/drugBank/FDA_labels/019700.pdf | title = FDA Label for Ketorolac | publisher = US Food and Drug Administration | year = 2004 | accessdate = 2007-10-16]
United Kingdom, [cite web | url = http://www.netdoctor.co.uk/medicines/effect/pain/prescription_only_medicines.shtml | title = Pain: prescription-only medicines | publisher = NetDoctor.co.uk | accessdate = 2007-10-16 | year = 2007] Canada, [cite web | url = http://www.smartmed.ca/content/search.asp?txtsearch=Ketorolac | title = Prescription Drug Search | publisher = Smart Med Canada | accessdate = 2007-10-16] and Australia [cite web | url = http://www.roche-australia.com/downloads/toradol-pi.cfm?action=get | title = Toradol (ketorolac trometamol) Product Information | year = 2005 | publisher = Roche Australia | accessdate = 2007-10-16] this drug cannot be sold over-the-counter and must be administered only with a prescription. It is commonly available over-the-counter in Mexico and other areas of Latin America, at the pharmacist's discretion.
Syntexcompany, of Palo Alto, Californiadeveloped the ophthalmic solution Acular, and holds the registered trademark on that name, as well as on the Toradol. The actual product using this brand name is manufactured and distributed by Allerganunder license from Syntex.cite web | last = Allergan | authorlink = Allergan | year = 2006 | url = http://www.allergan.com/site/products/consumers/home.asp?id=acular | title = ACULAR Ketorolac tromethamine 0.5% ophthalmic solution Product Information | work = Allergan web site | publisher = Allergan | accessdate = 2006-05-08] Apotex, a Canadian manufacturer, offers generic Ketorolac tromethamine 0.5% ophthalmic solution under the name "Apo-Ketorolac"cite web
last = Apotex Products Canada | authorlink = Apotex | date =
2006-05-08| url = http://www.apotex.ca/Products/EN/Detail.asp?MaterialNumber=000000000000043869 | title = APO-KETOROLAC Product Information | work = Apotex Products Canada Product Catalogue | publisher = Apotex Products Canada | accessdate = 2006-05-08] in Canada and some other countries. Syntex and Allergan sued Apotex for patent infringementof US PatentNo. 5,110,493, over the generic ketorolac tomethamine product. In May, 2005, the United States Court of Appealsfor the Federal Circuit handed Apotex a victory, ruling that a lower court upholding the Syntex patent misapplied the rules for judging whether an invention was obvious. Allergan had claimed that the patent is valid until 2009.cite web | last = Albainy-Jenei | first = Stephen R. | date = May 24, 2005| url = http://www.patentbaristas.com/archives/000188.php | title = Federal Circuit Reverses Allergan's Patent Validity Decision | work = Patent Baristas web log | accessdate = 2006-05-08]
* [http://www.druglib.com/druginfo/toradol/abstracts/ Published studies related to ketorolac] ] , at DrugLib
* [http://www.medicinenet.com/ketorolac_tromethamine-ophthalmic/article.htm MedicineNet.com information] on ophthalmic ketorolac
* Handley, D.A., P. Carvoni, J.E. McCray, J.R. McCullough (1998). "Preclinical Enantioselective Pharmacology of (R)- and (S)- Ketorolac.", "J Clin Pharmacol" 38, 25-35.
* 1993. "Physicians' Desk Reference, Forty-seventh edition". Montvale, N.J., Medical Economics Co. Inc., 2411-2415.
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