Active substanceKetorolacKetorolac
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  • Dosage form: & nbspsolution for intravenous and intramuscular administration
    Composition:

    1 ml of the preparation contains:

    active substance: ketorolac trometamol 30 mg;

    Excipients: ethanol 96% 100 mg, sodium chloride 4.35 mg, sodium hydroxide to adjust pH 7.4, water for injection up to 1 ml.

    Description:

    Transparent, from a colorless to light yellow solution.

    Pharmacotherapeutic group:Non-steroidal anti-inflammatory drug (NSAID)
    ATX: & nbsp

    M.01.A.B.15   Ketorolac

    Pharmacodynamics:Ketorolac belongs to non-steroidal anti-inflammatory drugs (NSAIDs), has a pronounced analgesic effect, and has an anti-inflammatory and moderate antipyretic effect. The mechanism of action is associated with nonselective inhibition of cyclooxygenase 1 (COX 1) and cyclooxygenase 2 (COX 2) activity catalyzing the formation of prostaglandins (Pg) from arachidonic acid, which play an important role in the pathogenesis of pain, inflammation and fever. Ketorolac is a racemic mixture [-]S and [+]R enantiomers, while the analgesic effect is due to [-]S form.By the strength of analgesic action comparable to morphine, it is significantly superior to other NSAIDs. The onset of analgesic action occurs after 0.5 h, the maximum effect is achieved in 1-2 hours and lasts about 4-6 hours.
    Pharmacokinetics:

    Suction. Bioavailability is complete and fast. After intramuscular injection, 30 mg maximum concentration (Cma) - 1.74-3.1 μg / ml, 60 mg - 3.23-5.77 μg / ml, the time to reach the maximum concentration (Tcmax) - 15-73 min and 30-60 min respectively. After intravenous administration at dose of 15 mg Cmah is 1.96-2.98 mcg / ml, in a dose of 30 mg - Cmah is 3.69-5.61 μg / ml.

    Distribution. The connection with plasma proteins is 99%. Time to reach equilibrium concentration (Css) - 24 hours, Css when administered intramuscularly 15 mg 4 times a day - 0.65-1.13 μg / ml, 30 mg - 1.29-2.47 μg / ml.

    The volume of distribution is 0.15-0.33 l / kg. In patients with renal insufficiency, the distribution of ketorolac may increase by a factor of 2, and the volume of distribution of ketorolac R-enantiomer by 20%.

    Penetrates into breast milk: after the administration of 10 mg ketorolac Cmin milk is reached after 2 hours and is 7.3 ng / ml, 2 hours after the second dose of ketorolac (with the drug 4 times a day) - is 7.9 ng / l.

    Metabolism. More than 50% of the administered dose is metabolized in the liver with the formation of pharmacologically inactive metabolites. The main metabolites are glucuronides, which are excreted by the kidneys, and p-hydroxysilicate. It is excreted 91% by the kidneys, 6% by the intestine.

    Excretion. The half-life (T1/2) In patients with normal renal function, an average of 5.3 hours (3.5-9.2 hours after intramuscular injection of 30 mg). T1/2 increases in elderly patients and decreases in young patients. The function of the liver has no effect on T1/2. In patients with impaired renal function with a creatinine concentration in the plasma of 19-50 mg / l (168-442 μmol / L) T1/2 is 10.3-10.8 hours, with more pronounced renal failure - more than 13.6 hours. The total clearance for intramuscular injection of 30 mg is 0.023 l / h / kg, with intravenous injection of 30 mg - 0.03 l / kg / h.

    Ketorolac is not excreted by hemodialysis.

    Indications:

    Pain syndrome of strong and moderate severity: trauma, toothache, pain in the postoperative period, oncological diseases, myalgia, arthralgia, neuralgia, sciatica, dislocations, sprains, rheumatic diseases.

    It is intended for symptomatic therapy, reducing pain and inflammation at the time of application, the progression of the disease is not affected.

    Contraindications:

    - Hypersensitivity to any component of the drug;

    - anamnestic data on the attack of bronchial obstruction, rhinitis, urticaria after taking acetylsalicylic acid or other NSAIDs (complete or incomplete combination of bronchial asthma, nasal polyposis and paranasal sinuses and intolerance to acetylsalicylic acid and other NSAIDs);

    - hypovolemia (regardless of the cause that caused it);

    - erosive and ulcerative lesions of the gastrointestinal tract in the acute stage, peptic ulcers, bleeding or high risk of their development, hypocoagulation (including hemophilia), inflammatory bowel disease (Crohn's disease, ulcerative colitis);

    - severe hepatic impairment or active liver disease;

    - severe renal failure (serum creatinine> 700 μmol / L), progressive kidney disease;

    - confirmed hypokalemia;

    - decompensated heart failure, condition after coronary artery bypass grafting;

    - The drug is not used for anesthesia before and during surgery because of the high risk of bleeding;

    - simultaneous administration with probenecid, pentoxifylline, lithium salts;

    - It is not recommended simultaneous use with anticoagulants, including warfarin and heparin;

    - intracranial hemorrhage or suspicion of it;

    - confirmed hyperkalemia;

    - pregnancy, the period of childbirth, the period of breastfeeding;

    - children under 16 years of age (efficacy and safety not established).

    Carefully:

    Hypersensitivity to other NSAIDs, bronchial asthma, the presence of factors that increase toxicity in relation to the gastrointestinal tract (alcoholism, smoking, cholecystitis); postoperative period; chronic heart failure (CHF), ischemic heart disease (IHD), edematous syndrome, hypertension; renal failure of moderate severity (serum creatinine 300-700 μmol / l); cholestasis; sepsis; systemic lupus erythematosus; simultaneous reception with other NSAIDs, long-term intake of NSAIDs; cerebrovascular diseases; Dyslipidemia, hyperlipidemia, diabetes mellitus; diseases of peripheral arteries; ulcerative lesions of the gastrointestinal tract in the anamnesis, the presence of infection H. pylori; severe physical illness; systemic connective tissue diseases; inflammatory bowel disease without exacerbation; simultaneous administration of oral glucocorticosteroid agents (including prednisolone),anticoagulants (including warfarin), antiplatelet agents (including clopidogrel), selective serotonin reuptake inhibitors (including citalopram, fluoxetine, paroxetine, sertraline), elderly age (over 65 years).

    Pregnancy and lactation:

    It is not recommended to take the drug during pregnancy (adverse effect on the fetal cardiovascular system - premature closure of the arterial duct), during labor, in the early postpartum period (inhibits the synthesis of prostaglandins, the drug may adversely affect the blood circulation of the fetus and weaken the contractile activity of the uterus that increases the risk of uterine bleeding) and during breastfeeding (the drug penetrates into breast milk).

    If it is necessary to use the drug during lactation, it is necessary to stop the difficult feeding.

    Dosing and Administration:

    Intramuscularly, intravenously.

    The drug is intended for short-term use.

    The drug is administered intravenously struino for at least 15 seconds or intramuscularly slowly, deep into the gluteal muscle, in minimally effective doses in a minimally short course.If necessary, it is also possible to additionally use opioid analgesics in reduced doses.

    Single doses for single administration:

    - patients from 16 to 65 years old and weighing more than 50 kg - 60 mg (2 ml) intramuscularly or 30 mg (1 ml) intravenously;

    - patients over 65 years old, or with renal insufficiency (serum creatinine 170-442 μmol / L), or body weight less than 50 kg - 30 mg (1 ml) intramuscularly or 15 mg (0.5 ml) intravenously.

    Doses with repeated administration:

    - patients from 16 to 65 years old and weighing more than 50 kg - 30 mg (1 ml) intramuscularly or intravenously if necessary every 6 hours. The maximum daily dose should not exceed 90 mg (3 ml);

    - patients older than 65 years, or with renal insufficiency (serum creatinine 170-442 μmol / l), or body weight less than 50 kg - 15 mg (0.5 ml) intramuscularly or intravenously, if necessary every 6 hours. The maximum daily dose should not exceed 60 mg (2 ml).

    The maximum duration of treatment should not exceed 2 days.
    In the transition from parenteral administration of the drug to oral administration, the total daily dose of both dosage forms on the day of transfer should not exceed 90 mg for patients up to 65 children and 60 mg for patients over 65 years of age, or with renal insufficiency,or body weight less than 50 kg. In this case, the dose of the drug in tablets on the day of transition should not exceed 30 mg.
    Side effects:

    According to the World Health Organization (WHO), adverse events are classified according to their frequency of development as follows: very frequent (> 10%), frequent (> 1% and <10%), infrequent (> 0.1% and <1%), rare (> 0.01% and <0.1%), very rare (<0.01%), the frequency is unknown (the frequency can not be determined based on available data).

    Allergic reactions: infrequent - anaphylaxis or anaphylactoid reactions (skin discoloration, skin rash, urticaria, skin itch, tachypnea or dyspnea, edema of the eyelids, periorbital edema, shortness of breath, shortness of breath, heaviness in the chest).

    Local Reactions: frequent - burning or pain at the injection site.

    From the central nervous system: very frequent - headache; frequent - dizziness, snotty, increased sweating; infrequent - tremor, unusual dreams, hallucinations, euphoria, extrapyramidal symptoms of vertigo, paresthesia, depression, insomnia, nervousness, pathological thinking, loss of concentration, hyperkinesis,stupor, aseptic meningitis (fever, severe headache, cramps, stiff neck and / or back muscles), psychosis, fainting.

    From the skin: frequent - itching, rash (including maculopapular rash); infrequent - urticaria, toxic epidermal necrolysis (Lyell's syndrome), malignant exudative erythema (Stevens-Johnson syndrome), exfoliative dermatitis (fever with chills or without, hyperemia, densification or flaking of the skin, enlargement and / or soreness of the tonsils).

    From the urinary system: infrequent - hematuria, proteinuria, urinary retention, oliguria, polyuria, frequent urination, acute renal failure, back pain with or without hematuria and / or azotemia, interstitial nephritis, hyponatremia. hyperkalemia, hemolytic-uremic syndrome (hemolytic anemia, renal failure, thrombocytopenia, purpura).

    From the digestive system: very frequent - gastralgia, dyspepsia, nausea; frequent - diarrhea, constipation, flatulence, a feeling of fullness of the stomach, vomiting, stomatitis; infrequent - increased or decreased appetite, anorexia,erosive and ulcerative lesions of the gastrointestinal tract (including with perforation and / or bleeding - abdominal pain, spasm or burning in the epigastric region, blood in the feces or melena, vomiting with blood or the type of "coffee grounds", nausea, heartburn ), cholestatic jaundice, hepatitis, hepatomegaly, acute pancreatitis, polydipsia, dry mouth; frequency unknown - exacerbation of ulcerative colitis or Crohn's disease.

    From the hematopoiesis: frequent - purple; infrequent - anemia, eosinophilia. From the respiratory system: infrequent - bronchospasm or dyspnea, pulmonary edema, rhinitis, laryngeal edema (difficulty breathing).

    From the sense organs: Infrequent - a violation of taste, visual impairment (including blurred vision), decreased hearing, ringing in the ears.

    From the side of the cardiovascular system: frequent - increased blood pressure; infrequent - a feeling of palpitations, pallor of the skin, fainting, hyperemia; frequency unknown - lowering of arterial pressure, heart failure, myocardial infarction, stroke.

    From the side of the hemostasis system: infrequent - bleeding from a postoperative wound, epistaxis, rectal bleeding.

    Other: frequent - edema; infrequent - weight gain, fever, infections, asthenia, increased sweating, swelling of the tongue; the frequency is unknown - an increase in the concentration of urea and creatinine in the blood plasma.

    Overdose:

    Symptoms: abdominal pain, nausea, vomiting, erosive-ulcerative lesions of the gastrointestinal tract, impaired function of the nights, metabolic acidosis.

    Treatment: there is no specific antidote, gastric lavage is recommended, administration of adsorbents (Activated carbon) and symptomatic therapy (maintenance of vital body functions). Ketorolac is not excreted sufficiently by dialysis.

    Interaction:

    The simultaneous use of ketorolac with other NSAIDs, glucocorticosteroids, ethanol, corticotropin, calcium preparations increases the risk of ulceration of the gastrointestinal mucosa and the development of gastrointestinal bleeding.

    Simultaneous use with paracetamol increases the nephrotoxicity of ketorolac, with methotrexate increases hepato- and nephrotoxicity.

    He use simultaneously with paracetamol for more than 2 days.

    The combined use of ketorolac and methotrexate is possible only with the use of low doses of the latter and control of its concentration in the blood plasma.

    When appointed with other nephrotoxic drugs (including gold preparations), the risk of developing nephrotoxicity increases.

    Probenecid reduces plasma clearance and the volume of ketorolac distribution, increases its concentration in blood plasma and increases its half-life.

    Simultaneous application with anticoagulants - derivatives of coumarin and indanedione, heparin, thrombolytics (alteplase, streptokinase, urokinase), antiplatelet drugs, cephalosporins, valproic acid and acetylsalicylic acid increases the risk of bleeding.

    Reduces the effect of antihypertensive and diuretic drugs (reduces the synthesis of prostaglandins in the kidneys).

    Drugs that block tubular secretion, reduce the clearance of ketorolac and increase its concentration in the blood plasma.

    When combined with opioid analgesics, the doses of the latter can be significantly reduced.

    Increases hypoglycemic action of insulin and oral hypoglycemic drugs (dose recalculation is necessary). Increases the concentration in the blood plasma of verapamil and nifedipine.

    Myelotoxic drugs increase the manifestation of hematotoxicity of the drug.

    It is not recommended simultaneous use with lithium salts, pentoxifylline, zidovudine, digoxin, tacrolimus, selective serotonin reuptake inhibitors, antacids, mifepristone.

    The drug should not be mixed in one syringe with morphine sulfate, meperidine hydrochloride, promethazine hydrochloride or hydroxyzine hydrochloride (ketorolac precipitated from the solution).

    Pharmaceutically incompatible with a solution of tramadol, lithium preparations.

    Special instructions:

    Before prescribing the drug, it is necessary to clarify the question of the previous allergy to ketorolac or other NSAIDs. Because of the risk of developing allergic reactions, the first dose is administered under close supervision of the doctor.

    Hypovolemia increases the risk of developing nephrotoxic adverse reactions.

    If necessary, can be used with opioid analgesics.

    It is not recommended to be used as a means for premedication, maintenance of anesthesia.

    When combined with other NSAIDs, fluid retention, cardiac decompensation, and increased blood pressure may occur.

    In patients with bleeding disorders, the drug is used only with a constant control of the number of platelets and hemostasis, which is especially important in the postoperative period. The effect on platelet aggregation stops after 24-48 hours.

    The risk of developing drug complications increases with prolonged treatment (in patients with chronic pain) and an increase in the dose of the drug.

    To reduce the risk of developing NSAIDs-gastropathy antacids are used, misoprostol, omeprazole.

    Effect on the ability to drive transp. cf. and fur:During the treatment period, care must be taken when driving vehicles and engaging in potentially dangerous activities that require a high concentration of attention and speed of psychomotor reactions.
    Form release / dosage:

    Solution for intravenous and intramuscular injection 30 mg / ml.

    Packaging:

    1 ml of the drug in ampoules of amber glass type 1, hermetically sealed.

    3 ampoules in a plastic pallet along with the instructions for use are placed in a cardboard box.

    Storage conditions:

    Store in a dark place at a temperature of no higher than 25 ° C.

    Keep out of the reach of children.

    Shelf life:

    3 years.

    Do not use after the expiration date.

    Terms of leave from pharmacies:On prescription
    Registration number:LP-003002
    Date of registration:22.05.2015
    Expiration Date:22.05.2020
    The owner of the registration certificate:Novator Pharma, LLCNovator Pharma, LLC United Kingdom
    Manufacturer: & nbsp
    Representation: & nbspNOVATOR PHARMA, LLCNOVATOR PHARMA, LLCRussia
    Information update date: & nbsp23.01.2017
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