Ketorolac Similar to Corticosteroid for Knee Osteoarthritis

Nancy A. Melville

March 30, 2015

NATIONAL HARBOR, MD — Intra-articular ketorolac (Toradol; Hoffmann-La Roche) achieved efficacy similar to that of corticosteroid injections in the treatment of knee osteoarthritis, a new study shows, representing a potential alternative treatment for the condition.

"Once you start running out of intra-articular injections for arthritis, the only real option is to start thinking about surgery, but our findings suggest ketorolac can be another tool in your arsenal," coauthor Siraj Sayeed, MD, from the Brooke Army Medical Center in Fort Sam Houston, Texas, told Medscape Medical News.

The study was presented here at the American Academy of Pain Medicine (AAPM) 31st Annual Meeting.

Corticosteroids and hyaluronic acid intra-articular injections are among the most common nonsurgical options for knee osteoarthritis, but results in terms of the degree and duration of pain relief can be inconsistent with both.

To evaluate the potential role of ketorolac (a potent nonsteroidal anti-inflammatory drug), Dr Sayeed and his colleagues randomly assigned 35 patients (36 knees) with knee osteoarthritis and a mean age of 52 years (range, 34 to 86 years) in a double-blind fashion to receive intra-articular injections with ketorolac or a corticosteroid, using ultrasound guidance for the injection.

The patients included 16 men and 20 women, with a mean Kellgren and Lawrence (KL) grade of 3 (range, 1 to 4).

In both groups, mean visual analogue scale (VAS) scores were reduced significantly 2 weeks after the injection, from 6.3 at baseline to 4.6 in the ketorolac group (P = .003) and from 5.2 to 3.6 in the corticosteroid (P = .003). The reductions remained in both groups through a 24-week follow-up.

In addition, mean Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores increased for the ketorolac (49 to 53) and corticosteroid groups (53 to 68; both also P = .003).

Other measures, including Knee Society pain and function, Short Form-36, and UCLA, showed no significant differences between the two groups, and there was no correlation between the VAS score and such variables as age, sex, body mass index, or KL grade of knee osteoarthritis.

"Pain relief initially and over time was similar between ketorolac and corticosteroid injection for knee osteoarthritis," the authors write.

"In regards to function, the WOMAC score was increased for both at two weeks, with no difference in other outcome measures. Ketorolac is a safe option for knee intra-articular injection."

Dr Sayeed noted that that the treatment could be particularly useful in younger patients.

"Ketorolac can be a useful alternative for all patients with arthritis, but especially for younger patients because you really can run out of options other than surgery if they fail to respond."

He noted that the idea to use ketorolac stemmed from the center's knee replacement pain management experience.

"Toradol is one of the medications used in our rapid recovery protocol for knee replacement," he explained. "It's beneficial as an anti-inflammatory drug and so we thought maybe we could try this prior to the replacement as well and that's where the idea came from."

Potential Benefits

Pain specialist Mehul J. Desai, MD, PhD, from George Washington University Hospital, Washington, DC, noted that the study's relatively small size is an important limitation, but he agreed on the potential benefits.

"I think the clinical significance of this study is the further establishment of ketorolac as a viable option or alternative to corticosteroid injection," he told Medscape Medical News.

"The sample size was relatively small; therefore some of the secondary outcome measures and even some of the primary measures may have been significantly different at the times evaluated with a larger group."

He agreed, however, that the benefits to an alternative to corticosteroid would be for patients who have had multiple injections or are not responsive to steroids.

"Also patients who might have allergies or for other reasons cannot have injectable steroids, reaching a large oral or systemic dose for the year." 

An important consideration with ketorolac, however, is potential adverse effects, Dr Desai noted.

"Ketorolac has fairly robust toxicity issues, including renal failure. Therefore understanding the patient's underlying medical conditions may be of greater importance."

The study received no outside funding. Dr Sayeed and Dr Desai have disclosed no relevant financial relationships.

Academy of Pain Medicine (AAPM) 31st Annual Meeting. Abstract 113. Presented March 20, 2015.

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