Intra-articular Ketorolac vs Steroid for Pain: Journal Club

Podcast Summary

This episode of the Pain Exam Podcast, hosted by Dr. David Rosenblum, discusses an interesting article about Ketorolac injections for musculoskeletal conditions. The podcast covers:

• Ketorolac is an NSAID that provides analgesic and anti-inflammatory effects through inhibition of prostaglandin synthesis

• Multiple studies comparing Ketorolac injections to corticosteroids and hyaluronic acid for various conditions

• Research shows Ketorolac injections are equally effective as corticosteroids for subacromial conditions, adhesive capsulitis, carpal-metacarpal joint issues, and hip/knee osteoarthritis

• Ketorolac may be a safer alternative to steroids for certain patients, though it has its own contraindications for those with renal, gastrointestinal, or cardiovascular disease

• Dr. Rosenblum considers the potential of using Ketorolac injections directly at pain sites rather than intramuscularly

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• Ultrasound courses in New York and Costa Rica (check unwrappedpain.org)

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• Presenting at a primary care conference in London

• Teaching ultrasound at ISPN

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• Ketorolac Injections: An Effective Alternative for Musculoskeletal Pain Management

  Musculoskeletal conditions such as bursitis, adhesive capsulitis, and osteoarthritis affect millions and often require injectable therapies to reduce pain and inflammation. Traditionally, corticosteroid injections have been the mainstay treatment. However, concerns over side effects like tendon rupture, cartilage damage, and systemic hyperglycemia have prompted exploration of alternatives. A recent narrative review by Kiel et al. (2024) highlights ketorolac—a parenteral nonsteroidal anti-inflammatory drug (NSAID)—as a promising substitute for corticosteroids in musculoskeletal injections.

  

  Warning: OFF Label use of Ketorolac discussed. Please consult your physician.

  See full article  for details.

  Subacromial Ketorolac Injections for Shoulder Pain

  Subacromial bursitis and impingement syndrome are common causes of shoulder pain and disability. Several randomized controlled trials have shown that subacromial ketorolac injections provide pain relief and functional improvement comparable to corticosteroids:

  • Goyal et al. demonstrated significant reductions in pain scores after subacromial injection of 60 mg ketorolac versus 40 mg methylprednisolone, with no difference in outcomes between groups.
  • Taheri et al. found similar short-term pain relief at 1 and 3 months with either ketorolac or corticosteroid subacromial injections.
  • Kim et al. reported equivalent clinical improvement in rotator cuff syndrome patients receiving ketorolac or triamcinolone injections.
  • Min et al. noted ketorolac led to better forward flexion and patient satisfaction at 4 weeks compared to corticosteroids.

  These studies support ketorolac as an effective agent for subacromial injection, offering an alternative for patients where corticosteroid use is limited.

  Intra-articular Ketorolac Injections for Adhesive Capsulitis and Osteoarthritis

  Adhesive capsulitis (frozen shoulder) and osteoarthritis of the hip, knee, and carpometacarpal joint are often treated with intra-articular corticosteroids. Ketorolac injections have shown comparable efficacy in these conditions:

  • Akhtar et al. found intra-articular ketorolac significantly reduced shoulder pain at 4 weeks in adhesive capsulitis compared to hyaluronic acid.
  • Ahn et al. reported similar pain relief between intra-articular ketorolac and corticosteroid injections in adhesive capsulitis, with ketorolac providing superior shoulder mobility at 3 and 6 months.
  • Koh et al. showed that adding ketorolac to hyaluronic acid injections in carpometacarpal osteoarthritis resulted in faster onset of pain relief compared to hyaluronic acid alone.
  • Park et al. observed equivalent functional improvements with intra-articular ketorolac or corticosteroids in hip osteoarthritis.
  • Jurgensmeier et al. demonstrated similar symptom improvement at 1 and 3 months post-injection for ketorolac and triamcinolone in hip and knee osteoarthritis.
  • Xu et al. and Bellamy et al. confirmed ketorolac’s comparable pain relief and functional benefits to corticosteroids for knee osteoarthritis, with ketorolac being more cost-effective.
  • Lee et al. noted quicker pain reduction with intra-articular ketorolac combined with hyaluronic acid versus hyaluronic acid alone in knee osteoarthritis.

  aSafety and Pharmacologic Considerations

  Ketorolac’s anti-inflammatory action stems from cyclooxygenase inhibition, reducing prostaglandin synthesis. Its half-life is approximately 5.2–5.6 hours, and it is metabolized in the liver. Unlike corticosteroids, ketorolac avoids systemic hyperglycemia and cartilage damage risks. Animal and in vitro studies suggest ketorolac may protect cartilage by inhibiting inflammatory cytokines.

  While gastrointestinal, renal, and cardiovascular risks associated with NSAIDs remain considerations, localized intra-articular and subacromial ketorolac injections may limit systemic exposure and adverse effects. Mild, transient post-injection pain has been reported but resolves without intervention.

  Conclusion

  Ketorolac injections, administered intra-articularly or subacromially, are a safe, effective, and economical alternative to corticosteroids for managing common musculoskeletal conditions. Their comparable efficacy in reducing pain and improving function, combined with a more favorable side effect profile, makes ketorolac an appealing option for clinicians and patients alike. Further research is warranted to fully elucidate long-term safety and optimal dosing strategies.

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  FAQS

  Ketorolac Injections for Musculoskeletal Conditions: Frequently Asked Questions

  Musculoskeletal pain from conditions like bursitis, adhesive capsulitis, and osteoarthritis often requires injectable treatments. Ketorolac, a nonsteroidal anti-inflammatory drug (NSAID), is emerging as a promising alternative to corticosteroids. Below are common questions and answers based on a recent narrative review by Kiel et al. (2024).

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  1. What is ketorolac and how does it work?

  Ketorolac is a parenteral NSAID that reduces pain and inflammation by inhibiting cyclooxygenase enzymes, which decreases prostaglandin synthesis. It can be administered orally, intramuscularly, intravenously, or by injection directly into joints or around bursae.

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  2. How effective is ketorolac for musculoskeletal conditions?

  Studies show ketorolac injections provide significant pain relief and functional improvement comparable to corticosteroids in conditions like:

  • Subacromial bursitis and shoulder impingement (subacromial injections)
  • Adhesive capsulitis (frozen shoulder) (intra-articular injections)
  • Osteoarthritis of the hip, knee, and thumb carpometacarpal joint (intra-articular injections)

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  3. What evidence supports subacromial ketorolac injections?

  Randomized controlled trials found:

  • Goyal et al. and Taheri et al. reported similar pain reduction and functional outcomes between ketorolac and corticosteroids for subacromial injections.
  • Kim et al. and Min et al. observed comparable or better patient satisfaction and shoulder mobility with ketorolac versus corticosteroids.

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  4. How does intra-articular ketorolac compare to corticosteroids for adhesive capsulitis?

  • Akhtar et al. showed ketorolac reduced shoulder pain more than hyaluronic acid.
  • Ahn et al. found ketorolac and corticosteroids equally effective for pain relief, with ketorolac providing better shoulder mobility at 3 and 6 months.

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  5. What about ketorolac for osteoarthritis?

  • Ketorolac combined with hyaluronic acid provided faster pain relief than hyaluronic acid alone in thumb carpometacarpal joint osteoarthritis (Koh et al.).
  • Intra-articular ketorolac had similar efficacy to corticosteroids in hip (Park et al., Jurgensmeier et al.) and knee osteoarthritis (Bellamy et al., Xu et al.).
  • Ketorolac injections were more cost-effective compared to corticosteroids (Bellamy et al.).

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  6. Are ketorolac injections safe?

  Ketorolac's side effects are similar to other NSAIDs, mainly involving gastrointestinal, renal, and cardiovascular risks. However, localized intra-articular and subacromial injections may reduce systemic exposure. Animal studies suggest ketorolac does not harm cartilage and may protect against inflammatory damage. Mild, transient local pain post-injection is possible but usually resolves without treatment.

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  7. What are the limitations of ketorolac use?

  Ketorolac is not suitable for patients with:

  • Renal impairment
  • Gastrointestinal ulcers or bleeding risk
  • Cardiovascular disease or hypertension
  • NSAID hypersensitivity, especially in asthma or chronic urticaria patients

  Clinicians should assess individual risks before choosing ketorolac injections.

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  8. How does ketorolac’s pharmacokinetics affect its use?

  Ketorolac has a plasma half-life of about 5.2 to 5.6 hours and is metabolized in the liver. Pharmacokinetics for subcutaneous or intra-articular administration are less defined but systemic absorption occurs. Its relatively short half-life supports repeated dosing if needed.

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  9. Why consider ketorolac over corticosteroids?

  Ketorolac avoids corticosteroid-associated risks such as tendon rupture, cartilage damage, and steroid-induced hyperglycemia. It is also more cost-effective, making it a favorable option for patients and healthcare systems.

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  10. What further research is needed?

  More large-scale, long-term studies are needed to fully understand ketorolac’s intra-articular effects, optimal dosing, and safety profile compared to corticosteroids and other treatments.

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  Summary:
  Ketorolac injections, whether intra-articular or subacromial, offer a safe, effective, and economical alternative to corticosteroids for managing various musculoskeletal conditions. This makes ketorolac an important option in pain management and inflammation control.

   

   

  Reference:

  Kiel J, Applewhite AI, Bertasi TGO, Bertasi RAO, Seemann LL, Costa LMC, Helmi H, Pujalte GGA. Ketorolac Injections for Musculoskeletal Conditions: A Narrative Review. Clinical Medicine & Research. 2024;22(1):19-27. DOI: https://doi.org/10.3121/cmr.2024.1847

  

  Disclaimer: This Podcast, website and any content from NRAP Academy (PMRexam.com) otherwise known as Qbazaar.com, LLC is  for general informational purposes only and does not constitute the practice of medicine, nursing or other professional health care services, including the giving of medical advice, and no doctor/patient relationship is formed. The use of information on this podcast or materials linked from this podcast is at the user’s own risk. Professionals should conduct their own fact finding, research, and due diligence to come to their own conclusions for treating patients. The content of this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice for any medical condition they may have and should seek the assistance of their health care professionals for any such conditions.