High or Low-Dose IM Ketorolac for Musculoskeletal Pain?

Written by Carmen Wolfe

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For ketorolac dosing in acute musculoskeletal pain, 15mg IM was non-inferior to 60 mg IM.

Why does this matter?
Opioid-sparing pain management options are essential in the ED, and ketorolac is one our staples. While JF has reviewed several articles (here and here) regarding IV dosing of ketorolac, what can the literature teach us about IM dosing? Can we get maximum analgesia with minimal dosing?

Same Story, Different Route
In this single-blinded non-inferiority trial, 110 adults with acute musculoskeletal pain were randomized to either 15 mg or 60 mg of IM ketorolac. For the primary outcome, a standard 100 mm visual analog scale was used to measure change in pain at 60 minutes. The group receiving 15 mg reported a decrease in pain from baseline of 29.7 (SD 22.5) vs the 60 mg dose group whose decrease in pain was 29.9 (SD 23.1). The mean difference between the groups was 0.1 mm (95%CI -8.5 to 8.7), which was less than the predetermined non-inferiority margin of 13mm.

This small study really only tells us that 15mg IM isn’t worse than 60mg IM, but from this information, paired with other literature, we can extrapolate that using the lowest effective dose is the winning strategy for ketorolac – helping us maximize analgesia and minimize adverse effects like GI bleeding, platelet inhibition, and renal impairment.

Comparing two doses of intramuscular ketorolac for treatment of acute musculoskeletal pain in a military emergency department. Am J Emerg Med. 2021 Jul 31;50:142-147. doi: 10.1016/j.ajem.2021.07.054. Online ahead of print.

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