In this episode, I’ll discuss the ceiling dose of ketorolac for renal colic in the ED.
The analgesic ceiling dose of ketorolac is 10 mg, and this has been established in several articles going as far back as more than 30 years ago.
In 1989, a study in the Journal of Clinical Pharmacology compared 10, 30, and 90 mg of IM ketorolac with placebo in 126 patients with cancer pain. While all doses were more effective than placebo, there was no difference in effectiveness between 10, 30, or 90 mg of IM ketorolac.
In 1990, a study in Pharmacotherapy compared 2 or 4 mg IV morphine with 10 or 30 mg IV ketorolac in 122 patients who had undergone major surgery. Both doses of ketorolac were as effective as 4 mg morphine and more effective than 2 mg morphine in providing pain control. There was no difference in efficacy between 10 and 30 mg of ketorolac.
In 2016, a trial by Sergey Motov confirmed this data by demonstrating IV ketorolac has an analgesic ceiling dose of 10 mg in ED patients with moderate to severe acute pain.
Most recently, in December 2020 in Academic Emergency Medicine researchers published a non-inferiority randomized trial comparing the analgesic efficacy of 3 doses of intravenous ketorolac (10, 20, and 30mg) in adult patients presenting to the ED with renal colic. 165 patients were split evenly between the 3 groups. There was no significant difference found between groups for the primary pain-related outcome. This is yet another study demonstrating that the analgesic ceiling dose of ketorolac is 10 mg.
This data, together with the dose-related risk of GI bleeding from ketorolac documented in the prescribing information, has caused me to abandon using the 30 and 60 mg doses of ketorolac in my practice. Achieving a 10 mg dose routinely in practice is challenging because of the odd measurement this requires and the habit of practitioners to choose the standard vial size of 15 mg/mL as the lowest dose. Either FDA approval of a lower dosage size or an automatic substitution policy would likely be required to get IV ketorolac doses down to 10 mg routinely.
To access my free download area with 20 different resources to help you in your practice, go to pharmacyjoe.com/free.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.