Ketorolac Is Overprescribed in the Emergency Department

November 3, 2019

By Erik MacLaren

DENVER -- November 1, 2019 -- Many practitioners may be prescribing excessive doses of ketorolac to patients presenting to the emergency department, according to research presented here at the 2019 Annual Meeting of the American College of Emergency Physicians (ACEP).

Ketorolac is often used in the emergency department because it is an effective, non-opioid analgesic. However, this drug is also associated with dose-dependent side effects, making appropriate dosing levels important for optimising patient care.

Alexa Gingras, Wright State University, Dayton, Ohio, and colleagues reviewed electronic records from the emergency department at a local level 1 trauma centre for any patient who received a dose of ketorolac from January 1, 2012, to January 1, 2017. They compared the dose ordered to electronic prescribing codes for vial sizes of 15 mg, 30 mg, and 60 mg to determine the amount of drug wasted, and compared the amount of ketorolac administered to patients to the theoretical ceiling therapeutic dose.

For analgesic effects, recently published research supports a ceiling dose of ketorolac of between 10 and 15 mg for both the intravenous (IV) and intramuscular (IM) dosing.

“I was surprised to learn that the ceiling dose was the same for both routes of administration,” noted Dr. Gingras. “This is not common with other medications.”

The records analysed included 10,687 unique orders for ketorolac during the 5-year study period, and these exceeded the therapeutic dose ceiling, calculated at 15 mg per dose, by 492,830 mg. The amount of wasted ketorolac totalled 9895 mg during the 5-year period. The authors attribute this relatively low amount of waste to the frequency with which full 60 mg doses were prescribed. Overall, more than 90% of ketorolac orders generated no waste.

IM administration was much more common than IV administration at this centre, and the proportion of 60 mg doses ordered was much lower among patients who received IV ketorolac than those who received the drug IM. Among the different provider types, PA-Cs ordered 60 mg doses 95% of the time, followed by DOs at 91%, and MDs at 85%.

Dr. Gingras noted that this study considered the ceiling dose for analgesia only and that the ceiling dose for the anti-inflammatory effects of ketorolac is higher, so there may be good reasons to prescribe higher doses of ketorolac. However, the excess observed at this centre was substantial, and education for providers to use ketorolac more efficiently could improve patient outcomes without compromising analgesia.

[Presentation title: Ketorolac in the Emergency Department: Analysis of Use and Waste. Abstract 62]