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Ketorolac for Pain Management: A Review of the Clinical Evidence [Internet]

Non-steroidal anti-inflammatory drugs (NSAIDs) play an important role in the pain management in various clinical conditions such as headaches, menstrual disorders, postoperative pain, spinal and soft tissue pain, rheumatoid arthritis (RA), osteoarthritis (OA), and ankylosing spondylitis (AS) by blocking cyclooxygenase (COX) enzymes that are needed to produce prostaglandin.

Rapid Response Report: Summary with Critical Appraisal - Canadian Agency for Drugs and Technologies in Health.

Version: June 30, 2014
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[Increased risk of hemorrhagic complications and the use of ketorolac related to post-surgical thromboprophylaxis]

Bibliographic details: Martinez Granados F, Martinez Lazcano M T, Navarro Polo J N, Ordovas Baines J P.  [Increased risk of hemorrhagic complications and the use of ketorolac related to post-surgical thromboprophylaxis]. [Riesgo aumentado de complicaciones hemorragicas y uso de ketorolaco asociado a tromboprofilaxis postquirurgica.] Atencion Farmaceutica 2007; 9(5): 298-306

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2007

Perioperative ketorolac increases post-tonsillectomy hemorrhage in adults, but not children

OBJECTIVES/HYPOTHESIS: To evaluate the risk of post-tonsillectomy hemorrhage associated with perioperative ketorolac use.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2014

Non‐steroidal anti‐inflammatory drugs for treating fluid accumulation in the macula after cataract surgery

Cystoid macular oedema (CMO) is the accumulation of fluid in the macula (central retina) due to leakage from capillaries. Clinically significant CMO following cataract surgery is a complication of unknown cause. Acute CMO, defined as oedema of less than four months duration, often gets better spontaneously. This review included seven randomised controlled trials with a total of 266 participants. Four trials studied the effects of non‐steroidal anti‐inflammatory agents (NSAIDs) in chronic CMO while the other three examined the effect of NSAIDs in acute CMO. This review found two trials which showed that topical NSAID (0.5% ketorolac tromethamine ophthalmic solution) has a positive effect on chronic CMO and a third trial which was supportive of this finding (albeit not statistically significantly so). One study suggested no effect and our review suggests further work is needed for a more conclusive decision regarding use of NSAIDS in chronic CMO. Similarly, the effects of NSAIDs in acute CMO remain unclear and this too needs further investigation.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2012

Ketorolac therapy for the prevention of acute pseudophakic cystoid macular edema: a systematic review

To assess the effectiveness of ketorolac vs control for prevention of acute pseudophakic cystoid macular edema (CME). The following databases were searched: Medline (1950-June 11, 2011), The Cochrane Library (Issue 2, 2011), and the TRIP Database (up to 11 June 2011), using no language or other limits. Randomized controlled clinical trials (RCTs) were included that consisted of patients with acute pseudophakic cystoid macular edema, those comparing ketorolac with control, and those having at least a minimum follow-up of 28 days. In the four RCTs evaluating ketorolac vs control, treatment with ketorolac significantly reduced the risk of CME development at the end of treatment (≈ 4 weeks) compared to control (P=0.008; 95% confidence interval (0.03-0.58)). When analyzed individually, each individual study was statistically nonsignificant in its findings with the exception of one study. When the pooled relative risk was calculated, the large sample size of this systematic review led to overall statistical significance, which is attributable to the review's large sample size and not to the individual studies themselves. In this systematic review of four RCTs, two of which compared ketorolac with no treatment and two of which evaluated ketorolac vs placebo drops, treatment with ketorolac significantly reduced the risk of developing CME at the end of ≈ 4 weeks of treatment compared with controls. These results, however, should be interpreted with caution considering the paucity of large randomized clinical trials in the literature.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2012

Ketorolac in the treatment of acute migraine: a systematic review

This systematic review examined the effectiveness of parenteral ketorolac (KET) in acute migraine. Acute migraine headaches are common emergency department presentations, and despite evidence for various treatments, there is conflicting evidence regarding the use of KET. Searches of MEDLINE, EMBASE, Cochrane, CINAHL, and gray literature sources were conducted. Included studies were randomized controlled trials in which KET alone or in combination with abortive therapy was compared with placebo or other standard therapy in adult patients with acute migraine. Two reviewers assessed relevance, inclusion, and study quality independently, and agreement was measured using kappa (k). Weighted mean differences (WMD) and relative risks are reported with 95% confidence intervals (CIs). Overall, the computerized search identified 418 citations and 1414 gray literature citations. From a list of 34 potentially relevant studies (k = 0.915), 8 trials were included, involving over 321 (141 KET) patients. The median quality scores were 3 (interquartile range: 2-4), and two used concealed allocation. There were no baseline differences in 10-point pain scores (WMD = 0.07; 95% CI: -0.39, 0.54). KET and meperidine resulted in similar pain scores at 60 minutes (WMD = 0.31; -0.68, 1.29); however, KET was more effective than intranasal sumatriptan (WMD = -4.07; 95% CI: -6.02 to -2.12). While there was no difference in pain relief at 60 minutes between KET and phenothiazine agents (WMD = 0.82; 95% CI: -1.33 to 2.98), heterogeneity was high (I(2)  = 70%). Side effect profiles were similar between KET and comparison groups. Overall, KET is an effective alternative agent for the relief of acute migraine headache in the emergency department. KET results in similar pain relief, and is less potentially addictive than meperidine and more effective than sumatriptan; however, it may not be as effective as metoclopramide/phenothiazine agents.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2013

High-dose ketorolac affects adult spinal fusion: a meta-analysis of the effect of perioperative nonsteroidal anti-inflammatory drugs on spinal fusion

STUDY DESIGN: Meta-analysis of literature.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2011

Ketorolac does not increase perioperative bleeding: a meta-analysis of randomized controlled trials

BACKGROUND: Postoperative pain control is essential for optimal patient outcomes. Ketorolac is an attractive alternative for achieving pain control postoperatively, but concerns over postoperative bleeding have limited its use.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2014

Perioperative single dose ketorolac to prevent postoperative pain: a meta-analysis of randomized trials

The review concluded that single-dose ketorolac was effective to reduce post-operative pain as well as post-operative nausea and vomiting. However, interpretation of the data may have been limited by variation amongst studies and unclear study quality. The authors' conclusions reflect the presented evidence but in light of the mentioned limitations their conclusions should be interpreted carefully.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2012

The relative efficacy of meperidine for the treatment of acute migraine: a meta-analysis of randomized controlled trials

The authors concluded that meperidine is less effective for migraine headache than dihydroergotamine regimens and may be more likely to cause adverse events. Meperidine may also be less effective than antiemetics. A degree of caution may be necessary in interpreting these conclusions because the primary trials were small, their quality was mixed and there were marked differences between them.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2008

Analgesics for Osteoarthritis: An Update of the 2006 Comparative Effectiveness Review [Internet]

To update a previous report on the comparative benefits and harms of oral non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, over-the-counter supplements (chondroitin and glucosamine), and topical agents (NSAIDs and rubefacients, including capsaicin) for osteoarthritis.

Comparative Effectiveness Reviews - Agency for Healthcare Research and Quality (US).

Version: October 2011
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Drug Class Review: Nonsteroidal Antiinflammatory Drugs (NSAIDs): Final Update 4 Report [Internet]

We compared the effectiveness and harms of oral or topical nonsteroidal antiinflammatory drugs (NSAIDs) in the treatment of chronic pain from osteoarthritis, rheumatoid arthritis, soft tissue pain, back pain, and ankylosing spondylitis.

Drug Class Reviews - Oregon Health & Science University.

Version: November 2010
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Dementia: A NICE-SCIE Guideline on Supporting People With Dementia and Their Carers in Health and Social Care

This guideline has been developed to advise on supporting people with dementia and their carers in health and social care. The guideline recommendations have been developed by a multidisciplinary team of health and social care professionals, a person with dementia, carers and guideline methodologists after careful consideration of the best available evidence. It is intended that the guideline will be useful to practitioners and service commissioners in providing and planning high-quality care for those with dementia while also emphasising the importance of the experience of care for people with dementia and carers.

NICE Clinical Guidelines - National Collaborating Centre for Mental Health (UK).

Version: 2007
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Tonsillectomy for Obstructive Sleep-Disordered Breathing or Recurrent Throat Infection in Children [Internet]

To systematically review evidence addressing tonsillectomy in children with obstructive sleep-disordered breathing (OSDB) or recurrent throat infections.

Comparative Effectiveness Reviews - Agency for Healthcare Research and Quality (US).

Version: January 2017
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Symptomatic treatment of migraine in children: a systematic review of medication trials

This review evaluated the efficacy and tolerability of symptomatic treatment of migraine in children. The authors' conclusion that acetaminophen, ibuprofen and nasal sumatriptan are all effective treatments for migraine episodes in children may be overstated, as most treatments have only been tested in one or two small trials and some of the analysis might not have been entirely appropriate.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2005

Topical non‐steroidal anti‐inflammatory agents for diabetic cystoid macular oedema

We reviewed the evidence about the effect of non‐steroidal anti‐inflammatory drugs for diabetic cystoid macular oedema.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2015

NSAIDs used for pain relief after surgery may have only small, temporary negative effects on kidney function in adults with normal renal function

Nonsteroidal anti‐inflammatory drugs (NSAIDs) can be used to try and relieve pain after surgery. However, there have been concerns about the possible harmful effects of these drugs on the kidneys. The review of trials found that NSAIDs can cause small, temporary negative effects on the kidneys in adults, but no one in the trials experienced renal failure or serious kidney problems. These results may not apply to children or adults with decreased kidney function

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2009

Sickle Cell Acute Painful Episode: Management of an Acute Painful Sickle Cell Episode in Hospital

This guideline addresses the management of an acute painful sickle cell episode in patients presenting to hospital until discharge. This includes the use of pharmacological and non-pharmacological interventions, identifying the signs and symptoms of acute complications, skills and settings for managing an acute painful episode, and the information and support needs of patients.

NICE Clinical Guidelines - National Institute for Health and Clinical Excellence (UK).

Version: June 2012
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Pain control in first trimester surgical abortion.

Multiple methods of pain control in first trimester surgical abortion at less than 14 weeks gestational age using electric or manual suction aspiration are available, and appear both safe and effective. Pain control methods can be divided in local anesthesia, conscious sedation, general anesthesia and non‐pharmacological methods. Data to support the benefit of the widely used local aneathetic is inadequate. While general anesthesia achieved complete pain control during the procedure, other forms of anesthesia such as conscious sedation with a paracervical block improved postoperative pain control.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2009

Topical non‐steroidal anti‐inflammatory drugs (NSAIDs) for the treatment of pain in traumatic corneal abrasions

The aim of this Cochrane Review was to find out if topical (applied directly to the surface of the eye) non‐steroidal anti‐inflammatory drugs (NSAIDs) for traumatic corneal abrasions reduce pain. Cochrane researchers collected and analysed all relevant studies to answer this question. We found nine studies.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2017

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