公共衛生藥學暨藥事管理Hygiene Pharmacy and Pharmacy Administration 評估 Ketorolac 用於急診腹痛病人 汐止國泰綜合醫院藥劑科藥師吳宗儒 張意宜 摘要 Ketorolac (NSAIDs) NSAIDs NSAIDs 2 ketorolac 252 ketorolac 60 ketorolac ketorolac ketorolac (DDD) 壹 前言 Ketorolac (NSAIDs) 97 ketorolac NSAIDs NSAIDs ibuprofen ketorolac 1 (meta-analysis) NSAIDs (IM) 2,3 ketorolac NSAIDs 4 2012 SOS (safety of non-steroidal antiinflammatory drugs (NSAIDs)) ketolorac (relative risk; RR) 11.50 (95% CI (confidence interval) 5.56-23.78) 5 NSAIDs ketorolac (odds ratio; OR) 5.76 (95% CI 5.14-6.44) 7.46 (95% CI 4.96-17.71) 6-7 Ketorolac 8 ketorolac 124 THE JOURNAL OF TAIWAN PHARMACY Vol.31 No.1 Mar. 31 2015
共衛生藥學暨藥事管理 ketorolac ketorolac 貳 研究方法 2013 9 12013 10 31 ketorolac ( (International classification of disease ICD-9) 789.00-789.09) ICD-9 531-534 578.0 578.1 578.9 WHO (world health organization) (defined daily dose, DDD) ketorolac 0-19 20-39 40-59 60-79 80 ( ) 5 ketorolac ketorolac ketorolac ( ) NSAIDs 9 NSAIDs (ATC (Anatomical Therapeutic Chemical) M01A) 10 (ATC B01A C04A) / (SNRI/SSRI ATC N06AX N06AB) 公 Ketorolac ketorolac ketorolac Spss (statistical product and service solutions) ( ) (chi-squared test) 參 結果一 急診使用 ketorolac 注射劑的病人 2013 9 12013 10 31 7887 ketorolac 1019 (12.9%) 1092536 (52.6%)44.7 18.220-39 36.3% 804.4% () 表一急診使用 ketorolac 之病人統計資料 ( ) ( ) ( ) 0-19 34 (6.3%) 36 (7.4%) 20-39 194 (36.2%) 176 (36.4%) 40-59 212 (39.6%) 149 (30.8%) 60-79 82 (15.3%) 91 (18.8%) 80 14 (2.6%) 31 (6.6%) Total 536 (52.6%) 483 (47.4%) 44.7 18.2 二 腹痛診斷病人 ketorolac 252 ketorolac 24.7% 120132 43.2 16.920-3938.9% 40-59 38.1% 60-79 12.7% 80 4.0% 37 (14.6%) 40-5913 () 60-79 25% 80 40.0% 藥學雜誌 122 125 311 Mar. 31 2015
公共衛生藥學暨藥事管理Hygiene Pharmacy and Pharmacy Administration 表二急診使用 ketorolac 針劑且診斷為腹痛 (abdominal pain) 病人之統計資料 ( ) ( ) ( ) ( ) ( / %) 0-19 4 (1.6%) 12 (4.8%) 1 (6.25%) 20-39 48 (19.0%) 50 (19.8%) 11 (11.2%) 40-59 54 (21.4%) 42 (16.7%) 13 (13.5%) 60-79 14 (5.6%) 18 (7.1%) 8 (25.0%) 80 0 (0.0%) 10 (4.0%) 4 (40.0%) Total 120 (47.6%) 132 (52.4%) 37 三 返診情形 ( 表三 ) ( 一 ) 年齡與返診 252 ketorolac 90 21 40-59 7 0-19 0% 20-39 17.9% 40-59 18.9% 60-79 41.7% 80 44.4% ( 二 ) 病史與返診 252 (p = 0.004)90 (p = 0.132) ( 三 ) 單一診斷與返診 25275 24 62 (8.3%) 184 (16.7%) (p = 0.618) 表三腹痛 (abdominal pain) 診斷使用 ketorolac 針劑且於 5 日內返診有消化道相關診斷之病人資料 ( ) (n = 90) 5 ( ) 5/ % 0-19 4 (4.4%) 0 (0.0%) 0.0% 20-39 23 (25.6%) 5 (5.6%) 17.9% 40-59 30 (33.2%) 7 (7.8%) 18.9% 60-79 7 (7.8%) 5 (5.6%) 41.7% 80 5 (5.6%) 4 (4.4%) 44.4% (n = 90) 34 (37.7%) 7 (7.7%) P value 33 (36.7%) 14 (15.6%) P = 0.229 (n = 90) 13 (14.4%) 8 (8.9%) P = 0.132 56 (62.2%) 13 (14.5%) (n = 24) 4 (16.7%) 2 (8.3%) P = 0.618 14 (58.3%) 4 (16.7%) 126 THE JOURNAL OF TAIWAN PHARMACY Vol.31 No.1 Mar. 31 2015
共衛生藥學暨藥事管理四 藥品併用 252 ketorolac 18 NSAID 7 (38.9%) 6 (33.3%) SSRI/SNRI 5 (27.8%) 6 (33.3%) 17 (7.3%) 五 ketorolac 之使用劑量 10191092 ketorolac 1DDD 99.8% 1DDD 0.2% 60 241241 ketorolac1.0ddd 1DDD 99.6% 1DDD 0.4% () 圖ㄧ Ketorolac 的 DDD 在各年齡層的百分比肆 討論 Ketorolac opiods 公 Ketorolac 53 ketorolac 47 11 NSAIDs (the European Medicines Agency; EMA) 60 NSAIDs NSAIDs ketorolac 60 1/5 60 16.7% ketorolac 99.6% 1DDD 12 ketorolac ketorolac ketorolac ketorolac NSAIDs aspirin aspirin ketorolac ketorolac 99.2% 97.5% ketorolac 2 藥學雜誌 122 127 311 Mar. 31 2015
公共衛生藥學暨藥事管理Hygiene Pharmacy and Pharmacy Administration 9,13 5 ketorolac ketorolac ketorolac ketorolac 60 伍 結論 14 ketorolac ketorolac ketorolac Evaluation of Ketorolac Used in ED Patients with Abdominal Pain Zong-Ru Wu, I-I Chang Department of Pharmacy, Sijhih Cathay General Hospital Abstract Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) widely used in the emergency department (ED) for short-term management of moderate to severe pain. Because of the potentially gastrointestinal adverse effects, NSAIDs used in patients with active or GI ulcer history were considered as contraindications. The analgesic efficacy of NSAIDs was proved to be different by using different administration routes, but the gastrointestinal adverse effects were higher when used parenterally. To recognize the appropriateness of using ketorolac in our ED, we collected the data of patients who diagnosed as abdominal 128 THE JOURNAL OF TAIWAN PHARMACY Vol.31 No.1 Mar. 31 2015
共衛生藥學暨藥事管理參考資料 : Ketorolac pain and were given ketorolac in ED retrospectively. There were 252 patients included in the 2 months periods. We found that high proportion of ketorolac prescriptions are not used appropriately, including high rates of ketorolac prescription above age 60, dosage was not prescribed individualized, prescribed in patients had GI ulcer history and in patients who currently taking drugs with high GI risk. Moreover, the 5-day readmission rate of patients with GI ulcers history showed a statistical significance compared with patients with no GI ulcers history. Therefore, to raise awareness of ketorolac use in clinical practice, carefully evaluation of the safe use of ketorolac by physician and pharmacist is very important. 1. Turturro MA, Paris PM, Seaberg DC. Intramuscular ketorolac case-crossover study in Taiwan. Pharmacoepideniology versus oral ibuprofen in acute musculoskeletal and drug safety; 2011; 20:763-771. pain. Ann Emerg Med. 1995 Aug; 26 (2):117-120. 7. Chang CH, Lin JW, Chen HC, et.al: Non-steroidal antiinflammatory 2. Ong CKS, Lirk P, Tan CH, et.al: An evidence-based update drug and risk of lower gastrointestinal ad- on nonsteroidal anti-inflammatory drugs. Clin Med verse events.gut.2011; 60(10):1372-1378. Res. 2007 Mar; 5(1): 19-34. 8. Jones A, Ramakrishnan K. Analgesics in the initial management 3. Ttamer MR, Williams JE, Carroll D, et.al: Comparing of acute abdominal pain. The Internet Journal of analgesic efficacy of non-steroidal anti-inflammatory Emergency Medicine. 2004; 2(2). drugs given by different routes in acute and chronic pain: 9. Product Information: TORADOL oral tablets, ketorolac A qualitative systematic review. Acta Anaesthesiol Scand tromethamine oral tablets. Roche Pharmaceuticals,Inc, 1998; 42: 71-79. Nutley, NJ, Jan 1, 2007. 4. Garcia-Rodriguez LA, Cattaruzzi C, Troncon MG, et.al: 10. Product Information: TORADOL, ketorolac tromethamine. Risk of hospitalization for upper gastrointestinal tract Roche Laboratories Inc., Nutley, NJ, 1996. bleeding associated with ketorolac, other nonsteroidal antiinflammatory 11. ADR drugs, calcium antagonists, and other antihy- -Ketorolac. Drug Safety Newsletter 2003.Mar, 1 12-15. pertensive drugs. Arch Intern Med 1998; 158(1):33-39. 12. Beers Criteria Update Expert Panel: American Geriatrics 5. Castellsague J, Riera-Guardia N, Calingaert B, et.al: Individual Society Updated Beers Criteria for Potentially Inappropri- NSAIDs and upper gastrointestinal complications ate Medication Use in Older Adults. J Am Geriatr Soc a systematic review and meta-analysis of observational 2012; 60(4):616-631. studies (the SOS Project) Drug Saf 2012; 35 (12): 1127-13. Product Information: SPRIX nasal spray, ketorolac tromethamine 1146. nasal spray. Roxro Pharma, Inc, Menlo Park, 6. Chang CH, Chen HC, Lin JW, et.al: Risk of hospitalization CA, Oct, 2009. for upper gastrointestinal adverse events associated 14. Fenyo G. Acute abdominal disease in the elderly: experience with non-steroidal anti-inflammatory drugs a nationwide from two series in Stockholm. Am J Surg 1982; 143: 751-4. 燦爛的色彩 311 Mar. 31 2015