TORADOL

Dr. Stuart B. Cherney

Team Physician StonyBrook Seawolves Long Island Lizards

TORADOL
THE GOOD

THE BAD

THE UGLY

THE GOOD

THE BAD

THE UGLY

What is it?

TORADOL = KETOROLAC Non-Steroidal AntiInflammatory

Approved in 1989

Indications:
Short term management of moderately severe acute pain that requires analgesia at the opioid level.

Inhibits prostaglandin synthesis COX 1 & COX 2

Excreted in urine

How GOOD is it?

800x more potent than Aspirin

More potent than Naproxen, Indomethacin, Phenalbutazone!

IM Analgesic efficacy superior to MORPHINE!

Oral Toradol definitely

NOT
as effective as IM/IV

Usage in USA
40

million injections in 2010 More than 500 million injections total

THE BAD

All adverse Effects After SINGLE IM dose 17% 41%.

After 5 days oral (but less than acetominophen) Ketorolac Adverse effects TWICE placebo.

Adverse Effects after Multiple IM doses of Ketorolac

Somnolence 7% Injection Site Pain 2% Sweating 1% Nausea 1% Less than 1% - Headache, Dizziness, Vomiting, Pruritus,
Vasodilation, Dysgeusia

After 1 year Oral Toradol 30mg/day

12% GI pain 11% dyspepsia 7% nausea

Inhibition of Platelet Aggregation

Prolonged Bleeding Time (?)
(except ADP triggered up to 48 hours)

Hypersensitivity

Bronchospasm -- Anaphylactic Shock Avoid If NSAID allergies exist Avoid If asthmatic

Do Not Use IF: Currently taking ASA / NSAIDS

BLACK BOX WARNINGS

Limitations of Use
- 5days

- Moderate/Moderately Severe Pain - Not indicated Minor/Chronic Pain

GI Risk
- Peptic Ulcers - GI bleeding / Perforation

Bleeding Risk
- Contraindicated in CVA; Hemorrhagic diasthesis; high risk

BLACK BOX WARNINGS

Cardiovascular Risk - may cause increased risk (MI & stroke) Renal Risk

- contraindicated if risk for renal failure secondary to volume depletion

THE UGLY
NFL LAWSUIT 12/5/11
Negligence, Fraud, Fraudulent Concealment, Negligent Misrepresentation, Conspiracy Repeatedly administering the painkiller Toradol Worsening high-risk injuries like concussions

Increased risk of bleeding Masking pain

THE UGLY
N.Y Times April 13, 2012

Concern Raised Over Painkillers Use in Sports

WHAT to do?

CURRENT STATUS
IOC ALL PROFESSIONAL SPORTS LEAGUES NCAA

Toradol

- Allowable - Classified as NSAID

TORADOL 2012 Game Day

Pain severe enough to prevent normal performance Injury which will not worsen Off other NSAIDs 24-48hrs No medical contraindications or allergies Athlete presented with treatment alternatives and advised of risks (waiver) Never to be used following concussion OR to mask potentially serious medical/orthopedic conditions

REMEMBER
Most issues regarding Toradol and concussion / bleeding are IDENTICAL to the use of ALL COX-1 NSAIDS

STAY TUNED