A review of ketorolac as a prehospital analgesic

Ketorolac was developed by the company Syntex, which gained Food and Drug Administration (FDA) approval for the drug, under the trade name Toradol, in November 1989 (Gupta and Devaraj, 2013; Stolberg, 2016). Ketorolac was the first injectable non-steroidal anti-inflammatory drug (NSAID) to gain FDA approval, with oral, ophthalmic and nasal preparations being approved in 1991, 1992 and 2010 respectively (Gupta and Devaraj, 2013).

In the UK, ketorolac is licensed for the short-term management of moderate-to-severe acute postoperative pain and, as such, its use for other causes of pain would be off-label. However, this is not a barrier to its use, as many of the drugs used routinely in prehospital care are also being used for off-label indications. The Medicine and Healthcare products Regulatory Agency (MHRA) (2007) has advised that treatment with ketorolac should only be initiated in hospitals. However, this advice was not meant to specifically exclude its use in the prehospital setting for a patient en route to hospital. It was concluded by MHRA Pharmacovigilance Service that owing to the relatively slow onset of action, ketorolac was less suitable for general prehospital use (Penny [MHRA Pharmacovigilance Service Team Manager], personal communication). In relation to current prehospital practice, the addition of ketorolac to prehospital care guidelines would provide paramedics with an intravenous (IV) or intramuscular (IM) NSAID. This would provide various prehospital analgesic options acting at various points of the pain pathway, facilitating the provision of effective multimodal analgesia.