Download ketorolac (kee-toe-role-ak) - DavisPlus

Name /bks_53161_deglins_md_disk/ketorolac
03/11/2014 08:41AM
1
ketorolac (kee-toe-role-ak)
Sprix, Toradol
Classification
Therapeutic: nonsteroidal anti-inflammatory agents, nonopioid analgesics
Pharmacologic: pyrroziline carboxylic acid
Pregnancy Category C (oral, nasal spray [⬍30 wk gestation]),
D (nasal spray [ⱖ30 wk gestation)
Indications
Short-term management of pain (not to exceed 5 days total for all routes combined).
Action
Inhibits prostaglandin synthesis, producing peripherally mediated analgesia. Also
has antipyretic and anti-inflammatory properties. Therapeutic Effects: Decreased pain.
Plate # 0-Composite
pg 1 # 1
alcohol intolerance (injection only); Perioperative pain from coronary artery bypass
graft (CABG) surgery; Cerebrovascular bleeding; Advanced renal impairment or at
risk for renal failure due to volume depletion; Concurrent use of pentoxifylline or
probenecid; OB: Chronic use in 3rd trimester may cause constriction of ductus arteriosus. May inhibit labor andqmaternal bleeding at delivery.
Use Cautiously in: Cardiovascular disease or risk factors for cardiovascular disease (mayqrisk of serious cardiovascular thrombotic events, myocardial infarction,
and stroke, especially with prolonged use); Heart failure; Coagulation disorders;
Mild-to-moderate renal impairment (dosage reduction may be required); Hepatic
impairment; Pedi: Safety not established in neonates; Geri: Appears on Beers list;q
risk of GI bleeding; Lactation: Lactation.
Adverse Reactions/Side Effects
CNS: STROKE, drowsiness, abnormal thinking, dizziness, euphoria, headache.
EENT: qlacrimation (spray), nasal discomfort (spray), throat irritation (spray).
Resp: asthma, dyspnea. CV: MYOCARDIAL INFARCTION, edema, pallor, vasodilation.
GI: GI BLEEDING, abnormal taste, diarrhea, dry mouth, dyspepsia, GI pain,qliver enzymes, nausea. GU: oliguria, renal toxicity, urinary frequency. Derm: EXFOLIATIVE
DERMATITIS, STEVENS-JOHNSON SYNDROME, TOXIC EPIDERMAL NECROLYSIS, pruritus, pur-
Pharmacokinetics
Absorption: Rapidly and completely absorbed following all routes of administra-
pura, sweating, urticaria. Hemat: prolonged bleeding time. Local: injection site
pain. Neuro: paresthesia. Misc: allergic reactions including, anaphylaxis.
tion.
Interactions
Drug-Drug: Probenecidqlevels and the risk of adverse reactions; concurrent
Distribution: Enters breast milk in low concentrations.
Protein Binding: 99%.
Metabolism and Excretion: Primarily metabolized by the liver. Ketorolac and
use is contraindicated.qrisk of bleeding when used with pentoxifylline; concurrent use is contraindicated. Concurrent use with aspirin maypeffectiveness.q
its metabolites are excreted primarily by the kidneys (92%); 6% excreted in feces.
adverse GI effects with aspirin, other NSAIDs, potassium supplements, corticoHalf-life: 4.5 hr (range 3.8– 6.3 hr;qin geriatric patients and patients with im- steroids, or alcohol. Maypeffectiveness of diuretics or antihypertensives. May
paired renal function).
qserum lithium levels andqrisk of toxicity.qrisk of toxicity from methotrexate.
qrisk of bleeding with cefotetan, cefoperazone, valproic acid, clopidogrel, tiTIME/ACTION PROFILE (analgesic effects)
clopidine, tirofiban, eptifibatide, thrombolytic agents, or anticoagulants.q
ROUTE
ONSET
PEAK
DURATION
risk of adverse hematologic reactions with antineoplastics or radiation therapy.
PO
unknown
2–3 hr
4–6 hr or longer
Mayqrisk of nephrotoxicity from cyclosporine.
IM, IV
10 min
1–2 hr
6 hr or longer
Drug-Natural Products: q bleeding risk with arnica, chamomile, clove,
IN
unknown
unknown
6–8 hr or longer
dong quai, feverfew, garlic, ginger, ginkgo, Panax ginseng.
Contraindications/Precautions
Contraindicated in: Hypersensitivity; Cross-sensitivity with other NSAIDs may exist; Preoperative use; Active or history of peptic ulcer disease or GI bleeding; Known
⫽ Canadian drug name.
⫽ Genetic Implication.
Route/Dosage
Oral therapy is indicated only as a continuation of parenteral therapy. Total duration
of therapy by all routes should not exceed 5 days.
CAPITALS indicate life-threatening, underlines indicate most frequent.
Strikethrough ⫽ Discontinued.
PDF Page #1
Name /bks_53161_deglins_md_disk/ketorolac
03/11/2014 08:41AM
Plate # 0-Composite
pg 2 # 2
2
● Lab Test Considerations: Evaluate liver function tests, especially AST and ALT,
PO (Adults ⬍65 yr): 20 mg initially, followed by 10 mg q 4– 6 hr (not to exceed 40
mg/day).
PO (Adults ⱖ65 yr, ⬍50 kg, or with renal impairment): 10 mg q 4– 6 hr (not to
exceed 40 mg/day).
PO (Children 2– 16 yr, ⬍50 kg): 1 mg/kg as a single dose. No data available for
multiple doses.
IM (Adults ⬍65 yr): Single dose— 60 mg. Multiple dosing— 30 mg q 6 hr (not to
exceed 120 mg/day).
IM (Adults ⱖ65 yr, ⬍50 kg, or with renal impairment): Single dose— 30 mg.
Multiple dosing— 15 mg q 6 hr (not to exceed 60 mg/day).
IM (Children 2– 16 yr, ⬍50 kg): Single dose— 0.4– 1 mg/kg (maximum: 30 mg/
dose). Multiple dosing— 0.5 mg/kg q 6 hr .
IV (Adults ⬍65 yr): Single dose— 30 mg. Multiple dosing— 30 mg q 6 hr (not to
exceed 120 mg/day).
IV (Adults ⱖ65 yr, ⬍50 kg, or with renal impairment): Single dose— 15 mg.
Multiple dosing— 15 mg q 6 hr (not to exceed 60 mg/day).
IV (Children 2– 16 yr, ⬍50 kg): Single dose— 0.4– 1 mg/kg (maximum: 15 mg/
dose). Multiple dosing— 0.5 mg/kg q 6 hr.
Intranasal (Adults ⬍65 yr): 1 spray in each nostril q 6– 8 hr (not to exceed 4
sprays in each nostril/day).
Intranasal (Adults ⱖ65 yr, ⬍50 kg, or with renal impairment): 1 spray in only
one nostril q 6– 8 hr (not to exceed 4 sprays in one nostril/day).
● May cause prolonged bleeding time that may persist for 24– 48 hr following dis-
NURSING IMPLICATIONS
Assessment
● Patients who have asthma, aspirin-induced allergy, and nasal polyps are
at increased risk for developing hypersensitivity reactions. Assess for
rhinitis, asthma, and urticaria.
● Assess for rash periodically during therapy. May cause Stevens-Johnson
syndrome or toxic epidermal necrolysis. Discontinue therapy if severe
or if accompanied with fever, general malaise, fatigue, muscle or joint
aches, blisters, oral lesions, conjunctivitis, hepatitis and/or eosinophilia.
● Pain: Assess pain (note type, location, and intensity) prior to and 1– 2 hr following administration.
periodically in patients receiving prolonged therapy. May causeqlevels.
continuation of therapy.
● May causeqBUN, serum creatinine, or potassium concentrations.
Potential Nursing Diagnoses
Acute pain (Indications)
Implementation
● Do not confuse Toradol (ketorolac) with tramadol (Ultram).
● Administration in higher-than-recommended doses does not provide increased
effectiveness but may cause increased side effects. Duration of ketorolac therapy, by all routes combined, should not exceed 5 days. Use lowest effective
dose for shortest period of time.
● Coadministration with opioid analgesics may have additive analgesic effects and
may permit lower opioid doses.
● PO: Ketorolac therapy should always be given initially by the IM or IV route. Use
oral therapy only as a continuation of parenteral therapy.
IV Administration
● Direct IV: Administer undiluted. Concentration: 15– 30 mg/mL. Rate: Ad-
minister over at least 15 sec.
● Y-Site Compatibility: alfentanil, amikacin, aminophylline, amphotericin B lipid
complex, amphotericin B liposome, anidulafungin, argatroban, ascorbic acid,
atracurium, atropine, aztreonam, benztropine, bivalirudin, bleomycin, bumetanide, buprenorphine, butorphanol, carboplatin, carmustine, cefazolin, cefoperazone, cefotaxime, cefotetan, cefoxitin, ceftazidime, ceftriaxone, cefuroxime,
chloramphenicol, cisatracurium, cisplatin, clindamycin, cyanocobalamin, cyclophosphamide, cyclosporine, cytarabine, dactinomycin, daptomycin, dexamethasone, dexmedetomidine, digoxin, docetaxel, dopamine, doxacurium, doxorubicin hydrochloride, enalaprilat, ephedrine, epinephrine, epoetin alfa, eftifibatide,
ertapenem, etoposide, etoposide phosphate, famotidine, fentanyl, fluconazole,
fludarabine, fluorouracil, folic acid, furosemide, gentamicin, glycopyrrolate,
granisetron, heparin, hydrocortisone, hydromorphone, ifosfamide, imipenem/cilastatin, indomethacin, insulin, irinotecan, isoproterenol, lidocaine, linezolid,
lorazepam, magnesium sulfate, mannitol, mechlorethamine, meperidine, methadone, methotrexate, methylprednisolone, metoclopramide, metoprolol, metro䉷 2015 F.A. Davis Company
CONTINUED
PDF Page #2
Name /bks_53161_deglins_md_disk/ketorolac
03/11/2014 08:41AM
Plate # 0-Composite
pg 3 # 3
3
● May cause drowsiness or dizziness. Advise patient to avoid driving or other activi-
CONTINUED
ketorolac
● Caution patient to avoid the concurrent use of alcohol, aspirin, NSAIDs, acetamin-
ties requiring alertness until response to the medication is known.
nidazole, milrinone, mitoxantrone, morphine, multivitamins, nafcillin, naloxone,
nesiritide, nitroglycerin, nitroprusside, norepinephrine, octreotide, ondansetron,
oxacillin, oxaliplatin, oxytocin, paclitaxel, palonosetron, pamidronate, pemetrexed, penicillin G, phenobarbital, phenylephrine, phytonadione, piperacillin/tazobactam, potassium acetate, potassium chloride, procainamide, propranolol,
ranitidine, remifentanil, sodium acetate, sodium bicarbonate, streptokinase, succinylcholine, sufentanil, tacrolimus, teniposide, theophylline, thiotepa, ticarcillin/
clavulanate, tigecycline, tirofiban, tobramycin, trimetaphan, vasopressin, verapamil, vincristine, voriconazole, zoledronic acid.
● Y-Site Incompatibility: acyclovir, amphotericin B colloidal, azathioprine, azithromycin, calcium chloride, caspofungin, chlorpromazine, dantrolene, diazepam,
diazoxide, diltiazem, diphenhydramine, dobutamine, doxycycline, epirubicin,
erythromycin, esmolol, fenoldopam, ganciclovir, gemcitabine, haloperidol, hydroxyzine, idarubicin, labetalol, levofloxacin, methoxamine, midazolam, mycophenolate, nalbuphine, pantoprazole, papaverine, pentamidine, pentazocine,
phentolamine, phenytoin, prochlorperazine, promethazine, protamine, pyridoxime, quinupristin/dalfopristin, rocuronium, tolazoline, trimethoprim/sulfamethoxazole, vancomycin, vecuronium, vinorelbine.
● Solution Compatibility: D5/0.9% NaCl, D5W, Ringer’s injection, lactated
Ringer’s injection, 0.9% NaCl.
● Intranasal: Activate pump before first use by holding bottle arm’s length away
with index finger and middle finger resting on top of finger flange and thumb supporting base. Press down evenly and release pump 5 times to activate. Prior to
each use, blow nose gently to clear nostrils. Sit up straight or stand. Tilt head
slightly forward. Insert tip of container into nostril. Point container away from center of nose. Push down to spray. Bottles are for 24 hr use; discard bottle no more
than 24 hours after taking first dose, even if the bottle still contains some liquid.
ophen, or other OTC medications without consulting health care professional.
● Advise patient to inform health care professional of medication regimen prior to
treatment or surgery.
● Advise patient to consult health care professional if rash, itching, visual disturbances, tinnitus, weight gain, edema, black stools, persistent headache, or influenza-like syndrome (chills, fever, muscle aches, pain) occurs.
● Intranasal: Instruct patient on correct technique for administration, need to
open a new bottle every 24 hr, and the 5 day limit for use.
Evaluation/Desired Outcomes
● Decrease in severity of pain. Patients who do not respond to one NSAID may re-
spond to another.
Why was this drug prescribed for your patient?
Patient/Family Teaching
● Instruct patient on how and when to ask for and take pain medication.
● Instruct patient to take medication exactly as directed. Take missed doses as soon
as remembered if not almost time for next dose. Do not double doses. Do not take
more than prescribed or for longer than 5 days.
⫽ Canadian drug name.
⫽ Genetic Implication.
CAPITALS indicate life-threatening, underlines indicate most frequent.
Strikethrough ⫽ Discontinued.
PDF Page #3