Ketorolac Dose Ceiling Effect for Pediatric Headache in the Emergency Department

Brian Lefchak; Danielle Morgan; Mike Finch; Manu Madhok; Mike Raschka

doi:10.5863/1551-6776-29.5.494

Ketorolac Dose Ceiling Effect for Pediatric Headache in the Emergency Department

J Pediatr Pharmacol Ther. 2024 Oct;29(5):494-500. doi: 10.5863/1551-6776-29.5.494. Epub 2024 Oct 14.

Authors

Brian Lefchak¹, Danielle Morgan², Mike Finch³, Manu Madhok¹, Mike Raschka²

Affiliations

¹ Department of Pediatric Emergency Medicine (BL, MM), Children's Minnesota, Minneapolis, MN.
² Pharmacy Department (DM, MR), Children's Minnesota, Minneapolis, MN.
³ Children's Minnesota Research Institute (MF), Children's Minnesota, Minneapolis, MN.

Abstract

Objective: This study sought to demonstrate a non-inferiority analgesic ceiling effect previously -demonstrated within adults for pediatric patients receiving a maximum ketorolac dose of 15 mg.

Methods: We conducted a retrospective cohort study of pediatric ED patients weighing at least 60 kg treated with 30 mg (pre-intervention) or 15 mg (post-intervention) intravenous (IV) ketorolac for headache. The primary outcome included patient-reported pain scores. Additional outcomes included demographic variables, adjunct medication use and adverse effects. Categorical data were evaluated using a χ² test, and numerical data were evaluated using an ANOVA F test and Welch 2-sample t test.

Results: The pre- and post-intervention groups included 216 and 62 patients, respectively. Overall demographics were similar between the groups (72.3% female, 49.3% White/Caucasian, mean age 15.5 years, mean weight 79.2 kg, and mean baseline 10-point pain score 7.5). Twelve (5.6%) in the pre-intervention group required rescue analgesic compared with 2 patients (3.2%) in the post-intervention group (p = 0.416). In the pre-intervention group, 198 patients (91.7%) received nausea medication compared with 52 patients (83.9%) in the post-intervention group (p = 0.087). Mean 10-point pain scores following ketorolac administration decreased by 3.9 in the pre-intervention group compared with 5.1 in the post-intervention group (p = < 0.001). Common (0.9%) or rare (0.9%) side effects were infrequent and only seen in the pre-intervention group patients.

Conclusions: Truncating the maximum intravenous ketorolac dose in pediatric patients at least 60 kg in weight to 15 mg compared with 30 mg results in effective analgesia in pediatric patients with headache. Future research could explore differences in admission rates, treatment of other indications, or treatment with multiple-dose regimens.

Keywords: dose; emergency department; headache; ketorolac; migraine; pediatric.