"Nov. 2, 2012 -- Safety steps taken in the wake of the fungal meningitis outbreak have worsened drug shortages, raising questions about whether the U.S. must choose between the safety and the availability of crucial medicines.
Limitations of Use
The total duration of use of SPRIX (ketorolac tromethamine nasal spray) alone or sequentially with other forms of ketorolac is not to exceed 5 days. SPRIX (ketorolac tromethamine nasal spray) must not be used concomitantly with other forms of ketorolac or other NSAIDs [see DOSAGE AND ADMINISTRATION].
Gastrointestinal (GI) Effects - Risk of Ulceration, Bleeding, and Perforation
SPRIX (ketorolac tromethamine nasal spray) is contraindicated in patients with previously documented peptic ulcers and/or GI bleeding [see CONTRAINDICATIONS]. Ketorolac tromethamine can cause serious GI adverse events including bleeding, ulceration, and perforation of the stomach, small intestine, or large intestine, which can be fatal. These serious adverse events can occur at any time, with or without warning symptoms, in patients treated with ketorolac.
Only one in five patients who develop a serious upper GI adverse event on NSAID therapy is symptomatic. Minor upper GI problems, such as dyspepsia, are common and may also occur at any time during NSAID therapy. The incidence and severity of GI complications increases with increasing dose of, and duration of treatment with, ketorolac. Even short-term therapy is not without risk. In addition to past history of ulcer disease, other factors that increase the risk for GI bleeding in patients treated with NSAIDs include concomitant use of oral corticosteroids or anticoagulants, longer duration of NSAID therapy, smoking, use of alcohol, older age, and poor general health status. Most spontaneous reports of fatal GI events are in elderly or debilitated patients, and therefore, special care should be taken in treating this population.
To minimize the potential risk for an adverse GI event, the lowest effective dose should be used for the shortest possible duration. Remain alert for signs and symptoms of GI ulceration and bleeding during NSAID therapy, and promptly initiate additional evaluation and treatment if a serious GI adverse event is suspected. This should include discontinuation of SPRIX (ketorolac tromethamine nasal spray) until a serious GI adverse event is ruled out. For high risk patients, consider alternate therapies that do not involve NSAIDs. Use great care when giving SPRIX (ketorolac tromethamine nasal spray) to patients with a history of inflammatory bowel disease (ulcerative colitis, Crohn's disease) as their condition may be exacerbated.
Because prostaglandins play an important role in hemostasis and NSAIDs affect platelet aggregation as well, use caution with use of ketorolac tromethamine in patients who have coagulation disorders, and monitor these patients carefully. The effects of NSAIDs other than aspirin on platelet function are reversible. Patients on therapeutic doses of anticoagulants (e.g., heparin or dicumarol derivatives) have an increased risk of bleeding complications if given ketorolac tromethamine concurrently; therefore, administer such concomitant therapy only with extreme caution. The concurrent use of ketorolac tromethamine and therapy that affects hemostasis, including prophylactic low dose heparin (2500 to 5000 units q12h), warfarin and dextrans, has not been studied extensively, but may also be associated with an increased risk of bleeding. Until data from such studies are available, carefully weigh the benefits against the risks and use such concomitant therapy in these patients only with extreme caution. Monitor patients receiving therapy that affects hemostasis closely.
In clinical trials, serious adverse events related to bleeding were more common in patients treated with SPRIX (ketorolac tromethamine nasal spray) than placebo. In clinical trials and in postmarketing experience with ketorolac IV and IM dosing, postoperative hematomas and other signs of wound bleeding have been reported in association with perioperative use. Therefore, use SPRIX (ketorolac tromethamine nasal spray) with caution in the postoperative setting when hemostasis is critical.
Anemia is sometimes seen in patients receiving NSAIDs. This may be due to fluid retention, occult or gross GI blood loss, or an incompletely described effect upon erythropoiesis. Do not use SPRIX in patients for whom hemostasis is critical [see CONTRAINDICATIONS, DRUG INTERACTIONS].
Ketorolac and its metabolites are eliminated primarily by the kidneys. Patients with reduced creatinine clearance will have diminished clearance of the drug [see CLINICAL PHARMACOLOGY]. SPRIX (ketorolac tromethamine nasal spray) is contraindicated in patients with advanced renal impairment [see CONTRAINDICATIONS].
In patients in whom renal prostaglandins have a compensatory role in the maintenance of renal perfusion, administration of an NSAID may cause a dose-dependent reduction in prostaglandin formation and renal blood flow, which may precipitate overt renal decompensation. Decreased intravascular volume such as when oral intake is poor increases the risks of renal toxicity with NSAIDs. Therefore, patients treated with SPRIX (ketorolac tromethamine nasal spray) should be adequately hydrated. Discontinuation of NSAID therapy is usually followed by recovery to the pretreatment state.
Use SPRIX (ketorolac tromethamine nasal spray) with caution in patients with impaired renal function, heart failure, liver dysfunction, those taking diuretics or ACE inhibitors, and the elderly. Assess the risks and benefits prior to giving SPRIX (ketorolac tromethamine nasal spray) to these patients, and follow these patients closely during SPRIX (ketorolac tromethamine nasal spray) therapy. Long-term administration of NSAIDs has resulted in renal papillary necrosis and other renal injury such as interstitial nephritis and nephrotic syndrome.
As with other NSAIDs, anaphylactoid reactions may occur in patients with or without a history of allergic reactions to aspirin or NSAIDs and in patients without known prior exposure to ketorolac. SPRIX (ketorolac tromethamine nasal spray) should be discontinued immediately in patients with allergic reactions. SPRIX (ketorolac tromethamine nasal spray) should not be given to patients with the aspirin triad. This symptom complex typically occurs in asthmatic patients who experience rhinitis with or without nasal polyps, or who exhibit severe, potentially fatal bronchospasm after taking aspirin or other NSAIDs [see CONTRAINDICATIONS, WARNINGS AND PRECAUTIONS]. Emergency help should be sought in cases where an anaphylactoid reaction occurs.
- Cardiovascular (CV) Thrombotic Events
Clinical trials of several COX-2 selective and nonselective NSAIDs of up to three years duration have shown an increased risk of serious CV thrombotic events, myocardial infarction and stroke, which can be fatal. All NSAIDs, both COX-2 selective and nonselective, may have a similar risk. Patients with known CV disease or risk factors for CV disease may be at greater risk. To minimize the potential risk for an adverse CV event in patients treated with an NSAID, the lowest effective dose should be used for the shortest duration possible. Physicians and patients should remain alert for the development of such events, even in the absence of previous CV symptoms. Patients should be informed about the signs and/or symptoms of serious CV events and the steps to take if they occur. There is no consistent evidence that concurrent use of aspirin mitigates the increased risk of serious CV thrombotic events associated with NSAID use. The concurrent use of aspirin and an NSAID increases the risk of serious GI events. Two large, controlled clinical trials of a COX-2 selective NSAID for the treatment of pain in the first 10-14 days following CABG surgery found an increased incidence of myocardial infarction and stroke [see CONTRAINDICATIONS, WARNINGS AND PRECAUTIONS, DRUG INTERACTIONS].
NSAIDs can lead to onset of new hypertension or worsening of preexisting hypertension, either of which may contribute to the increased incidence of CV events. Patients taking thiazides or loop diuretics may have impaired response to these therapies when taking NSAIDs [see DRUG INTERACTIONS].
- Congestive Heart Failure and Edema
Fluid retention, edema, retention of NaCl, oliguria, and elevations of serum urea nitrogen and creatinine have been reported in clinical trials with ketorolac. Therefore, only use SPRIX (ketorolac tromethamine nasal spray) very cautiously in patients with cardiac decompensation or similar conditions.
NSAIDs, including ketorolac, can cause serious skin adverse events such as exfoliative dermatitis, Stevens-Johnson Syndrome (SJS), and toxic epidermal necrolysis (TEN), which can be fatal. These serious events may occur without warning. Inform patients about the signs and symptoms of serious skin manifestations, and discontinue use of the drug at the first appearance of skin rash or any other sign of hypersensitivity [see CONTRAINDICATIONS].
Starting at 30 weeks gestation, SPRIX (ketorolac tromethamine nasal spray) can cause fetal harm when administered to a pregnant woman due to an increased risk of premature closure of the ductus arteriosus. If SPRIX (ketorolac tromethamine nasal spray) is used at or after 30 weeks gestation, the patient should be apprised of the potential hazard to a fetus [see Use In Specific Populations].
Use SPRIX (ketorolac tromethamine nasal spray) with caution in patients with impaired hepatic function or a history of liver disease. Borderline elevations of one or more liver tests may occur in up to 15% of patients taking NSAIDs, including ketorolac. These laboratory abnormalities may progress, may remain unchanged, or may be transient with continuing therapy. Notable elevations of ALT or AST (approximately three or more times the upper limit of normal) have been reported in approximately 1% of patients in clinical trials with NSAIDs. In addition, rare cases of severe hepatic reactions, including jaundice, fulminant hepatitis, liver necrosis, and hepatic failure, some of them with fatal outcomes, have been reported [see WARNINGS AND PRECAUTIONS, CLINICAL PHARMACOLOGY].
Evaluate patients with symptoms and/or signs suggesting liver dysfunction, or in whom an abnormal liver test has occurred, for evidence of the development of a more severe hepatic reaction while on therapy with SPRIX (ketorolac tromethamine nasal spray) . If clinical signs and symptoms consistent with liver disease develop, or if systemic manifestations occur (e.g., eosinophilia, rash, etc.), discontinue SPRIX (ketorolac tromethamine nasal spray) .
Inflammation and Fever
The pharmacological activity of SPRIX (ketorolac tromethamine nasal spray) in reducing inflammation and fever may diminish the utility of these diagnostic signs in detecting infections.
Patients with asthma may have aspirin-sensitive asthma. The use of aspirin in patients with aspirin-sensitive asthma has been associated with severe bronchospasm which can be fatal. Since cross reactivity, including bronchospasm, between aspirin and other NSAIDs has been reported in such aspirin-sensitive patients, do not administer SPRIX (ketorolac tromethamine nasal spray) to patients with this form of aspirin sensitivity, and use with caution in patients with preexisting asthma [see CONTRAINDICATIONS, WARNINGS AND PRECAUTIONS].
Avoid contact of SPRIX (ketorolac tromethamine nasal spray) with the eyes. If eye contact occurs, wash out the eye with water or saline, and consult a physician if irritation persists for more than an hour.
Patient Counseling Information
Instruct patients to read the NSAID Medication Guide that accompanies each prescription dispensed. Inform patients of the following information before initiating therapy with SPRIX (ketorolac tromethamine nasal spray) .
Instruct all patients to read and closely follow the FDA-approved SPRIX (ketorolac tromethamine nasal spray) Patient Instructions to ensure proper administration of SPRIX (ketorolac tromethamine nasal spray) . When prescribing SPRIX (ketorolac tromethamine nasal spray) , inform patients or their caregivers of the potential risks of ketorolac treatment, instruct patients to seek medical advice if they develop treatment-related adverse events, advise patients not to give SPRIX (ketorolac tromethamine nasal spray) to other family members, and advise patients to discard any unused drug.
Limitations of Use
Instruct patients not to use SPRIX (ketorolac tromethamine nasal spray) for more than 5 days. Use of SPRIX (ketorolac tromethamine nasal spray) alone or in combination with any other ketorolac product for more than 5 days increases the risk for serious complications including GI bleeding and renal injury.
Ketorolac is a potent NSAID and, like other NSAIDs, may cause serious side effects, such as gastrointestinal bleeding, which may result in hospitalization and even fatal outcome. Although serious GI tract ulcerations and bleeding can occur without warning symptoms, instruct patients to be alert for the signs and symptoms of ulcerations and bleeding, and to ask for medical advice when observing any indicative sign or symptom, including epigastric pain, dyspepsia, melena, and hematemesis. Instruct patients of the importance of this follow-up [see CONTRAINDICATIONS, WARNINGS AND PRECAUTIONS].
SPRIX (ketorolac tromethamine nasal spray) is eliminated by the kidneys. Advise patients to maintain adequate fluid intake and request medical advice if urine output decreases significantly [see CONTRAINDICATIONS, WARNINGS AND PRECAUTIONS].
Ketorolac, like other NSAIDs, may cause serious CV events, such as MI or stroke, which may result in hospitalization and even death. Although serious CV events can occur without warning symptoms, advise patients to be alert for the signs and symptoms of chest pain, shortness of breath, weakness, slurring of speech, and that they should ask for medical advice when observing any indicative sign or symptoms. Inform patients of the importance of this follow-up [see WARNINGS AND PRECAUTIONS].
Adverse Skin Reactions
Ketorolac, like other NSAIDs, can cause serious skin side effects such as exfoliative dermatitis, Stevens-Johnson Syndrome (SJS), and toxic epidermal necrolysis (TEN), which may result in hospitalization and even death. Although serious skin reactions may occur without warning, instruct patients to be alert for the signs and symptoms of skin rash and blisters, fever, or other signs of hypersensitivity such as itching, and should ask for medical advice when observing any indicative signs or symptoms. Advise patients to stop the drug immediately if they develop any type of rash, and contact their physicians as soon as possible [see WARNINGS AND PRECAUTIONS].
Weight Gain and Edema
Instruct patients to promptly report signs or symptoms of unexplained weight gain or edema to their physicians [see WARNINGS AND PRECAUTIONS].
Inform patients of the warning signs and symptoms of hepatotoxicity (e.g., nausea, fatigue, lethargy, pruritus, jaundice, right upper quadrant tenderness, and “flu-like” symptoms). If these occur, instruct patients to stop therapy and seek immediate medical therapy [see WARNINGS AND PRECAUTIONS].
Inform patients of the signs of an anaphylactoid reaction (e.g., difficulty breathing, swelling of the face or throat). If these occur, instruct patients to seek immediate emergency help [see CONTRAINDICATIONS, WARNINGS AND PRECAUTIONS].
Effects During Pregnancy
Avoid the use of SPRIX (ketorolac tromethamine nasal spray) at or beyond 30 weeks gestation as ketorolac can cause premature closure of the ductus arteriosus [see WARNINGS AND PRECAUTIONS, Use in Specific Populations)].
Single Day Container
Instruct patients not to use any single bottle of SPRIX for more than one day [see DOSAGE AND ADMINISTRATION].
Advise patients that they may experience transient, mild to moderate nasal irritation or discomfort upon dosing.
Carcinogenesis, Mutagenesis, and Impairment of Fertility
An 18-month study in mice with oral doses of ketorolac at 2 mg/kg/day (approximately 1.5 times the human systemic exposure at the recommended maximum IN dose of 31.5 mg qid, based on area-under-the-plasma-concentration curve [AUC]), and a 24-month study in rats at 5 mg/kg/day (approximately 0.8 times the human AUC) showed no evidence of tumorigenicity.
Ketorolac was not mutagenic in the Ames test, unscheduled DNA synthesis and repair, or in forward mutation assays. Ketorolac did not cause chromosome breakage in the in vivo mouse micronucleus assay. At 1590 μg/mL and at higher concentrations, ketorolac increased the incidence of chromosomal aberrations in Chinese hamster ovarian cells.
Impairment of fertility
Impairment of fertility did not occur in male or female rats at oral doses of 9 mg/kg (approximately 1.5 times the human AUC) and 16 mg/kg (approximately 2.7 times the human AUC) of ketorolac, respectively.
Use In Specific Populations
Pregnancy Category C prior to 30 weeks gestation; Category D starting at 30 weeks gestation.
SPRIX (ketorolac tromethamine nasal spray) can cause fetal harm when administered to a pregnant woman. Human data demonstrate that use of NSAIDs at or after 30 weeks gestation increases the risk of premature closure of the ductus arteriosus. If SPRIX (ketorolac tromethamine nasal spray) is used at or after 30 weeks gestation, the patient should be apprised of the potential hazard to a fetus. There are no adequate, well-controlled studies in pregnant women. Prior to 30 weeks gestation, SPRIX (ketorolac tromethamine nasal spray) should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.
Reproduction studies have been performed during organogenesis using daily oral doses of ketorolac tromethamine at 3.6 mg/kg (0.6 times the human systemic exposure at the recommended maximum IN dose of 31.5 mg qid, based on area-under-the-plasma-concentration curve [AUC]) in rabbits and at 10 mg/kg (1.7 times the human AUC) in rats. These studies did not reveal evidence of teratogenicity or other adverse developmental outcomes. However, because animal dosing was limited by maternal toxicity, these studies do not adequately assess ketorolac's potential to cause adverse developmental outcomes in humans.
Labor and Delivery
The effects of SPRIX (ketorolac tromethamine nasal spray) on labor and delivery in pregnant women are unknown. In rat studies, maternal exposure to NSAIDs, as with other drugs known to inhibit prostaglandin synthesis, increased the incidence of dystocia and delayed parturition, and decreased pup survival.
Ketorolac is excreted in human milk. Ten nursing mothers received 10 mg of oral ketorolac, four times a day, for two days. In four women, ketorolac was undetectable in milk (assay limit 5 ng/ml). In the remaining six women, ketorolac concentrations in milk ranged from 5.2 to 7.9 ng/ml. Based on these concentrations, the estimated maximum infant daily dose of ketorolac from breast milk is 1.185 mcg/kg/day. Exercise caution when administering SPRIX (ketorolac tromethamine nasal spray) to a nursing woman.
The safety and effectiveness of ketorolac in pediatric patients 17 years of age and younger have not been established.
Geriatric Use ( ≥ 65 years of age)
Exercise caution when treating the elderly (65 years and older) with SPRIX (ketorolac tromethamine nasal spray) . Carefully consider the potential benefits and risks of SPRIX (ketorolac tromethamine nasal spray) and other treatment options before deciding to use SPRIX (ketorolac tromethamine nasal spray) . Use the lowest effective dose for the shortest duration consistent with individual patient treatment goals [see DOSAGE AND ADMINISTRATION, WARNINGS AND PRECAUTIONS, CLINICAL PHARMACOLOGY]. After observing the response to initial therapy with SPRIX (ketorolac tromethamine nasal spray) , then adjust the dose and frequency to suit an individual patient's needs.
Last reviewed on RxList: 10/21/2011
This monograph has been modified to include the generic and brand name in many instances.
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