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Ketorolac Tromethamine

Dosage Form: injection

Indications and Usage for Ketorolac Tromethamine


Ketorolac Tromethamine ophthalmic solution is indicated for the temporary relief of ocular itching due to seasonal allergic conjunctivitis. Ketorolac Tromethamine ophthalmic solution is also indicated for the treatment of postoperative inflammation in patients who have undergone cataract extraction.


Ketorolac Tromethamine Dosage and Administration

Recommended Dosing


Patient Dosing
The recommended dose of Ketorolac Tromethamine ophthalmic solution is one drop four times a day to the affected eye(s) for relief of ocular itching due to seasonal allergic conjunctivitis.

For the treatment of postoperative inflammation in patients who have undergone cataract extraction, one drop of Ketorolac Tromethamine ophthalmic solution should be applied to the affected eye four times daily beginning 24 hours after cataract surgery and continuing through the first 2 weeks of the postoperative period.

Use with Other Topical Ophthalmic Medications


Ketorolac Tromethamine ophthalmic solution has been safely administered in conjunction with other ophthalmic medications such as antibiotics, alpha-agonists, beta blockers, carbonic anhydrase inhibitors, cycloplegics, and mydriatics. Drops should be administered at least 5 minutes apart.

Dosage Forms and Strengths

Ketorolac Tromethamine ophthalmic solution 0.5% is supplied sterile in white opaque LDPE dropper bottles with white opaque plug and sealed with gray pantone opaque pilfer-proof caps as follows: 


  • 5 mL size bottle filled with 3 mL of solution 
  • 5 mL size bottle filled with 5 mL of solution
  • 10 mL size bottle filled with 10 mL of solution

Contraindications


Ketorolac Tromethamine ophthalmic solution is contraindicated in patients with previously demonstrated hypersensitivity to any of the ingredients in the formulation.

Warnings and Precautions

Delayed Healing

Topical nonsteroidal anti-inflammatory drugs (NSAIDs) may slow or delay healing. Topical corticosteroids are also known to slow or delay healing. Concomitant use of topical NSAIDs and topical steroids may increase the potential for healing problems.

Cross-Sensitivity or Hypersensitivity


There is the potential for cross-sensitivity to acetylsalicylic acid, phenylacetic acid derivatives, and other NSAIDs. There have been reports of bronchospasm or exacerbation of asthma associated with the use of Ketorolac Tromethamine ophthalmic solution in patients who have either a known hypersensitivity to aspirin/non-steroidal anti-inflammatory drugs or a past medical history of asthma. Therefore, caution should be used when treating individuals who have previously exhibited sensitivities to these drugs.

Increased Bleeding Time


With some NSAIDs, there exists the potential for increased bleeding time due to interference with thrombocyte aggregation. There have been reports that ocularly applied nonsteroidal anti- inflammatory drugs may cause increased bleeding of ocular tissues (including hyphemas) in conjunction with ocular surgery.

It is recommended that Ketorolac Tromethamine ophthalmic solution be used with caution in patients with known bleeding tendencies or who are receiving other medications, which may prolong bleeding time.


Corneal Effects


Use of topical NSAIDs may result in keratitis. In some susceptible patients, continued use of topical NSAIDs may result in epithelial breakdown, corneal thinning, corneal erosion, corneal ulceration, or corneal perforation. These events may be sight threatening. Patients with evidence of corneal epithelial breakdown should immediately discontinue use of topical NSAIDs and should be closely monitored for corneal health.

Postmarketing experience with topical NSAIDs suggests that patients with complicated ocular surgeries, corneal denervation, corneal epithelial defects, diabetes mellitus, ocular surface diseases (e.g., dry eye syndrome), rheumatoid arthritis, or repeat ocular surgeries within a short period of time may be at increased risk for corneal adverse events which may become sight threatening. Topical NSAIDs should be used with caution in these patients.

Postmarketing experience with topical NSAIDs also suggests that use more than 1 day prior to surgery or use beyond 14 days post-surgery may increase patient risk for the occurrence and severity of corneal adverse events.


Contact Lens Wear

Ketorolac Tromethamine ophthalmic solution should not be administered while wearing contact lenses.

Adverse Reactions

Clinical Studies Experience

Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of a drug cannot be directly compared to the rates in the clinical studies of another drug and may not reflect the rates observed in practice.


The most frequent adverse reactions reported with the use of Ketorolac Tromethamine ophthalmic solutions have been transient stinging and burning on instillation. These reactions were reported by up to 40% of patients participating in clinical trials.


Other adverse reactions occurring approximately 1 to 10% of the time during treatment with Ketorolac Tromethamine ophthalmic solutions included allergic reactions, corneal edema, iritis, ocular inflammation, ocular irritation, superficial keratitis, and superficial ocular infections.


Other adverse reactions reported rarely with the use of Ketorolac Tromethamine ophthalmic solutions included: corneal infiltrates, corneal ulcer, eye dryness, headaches, and visual disturbance (blurry vision).

Postmarketing Experience

The following adverse reactions have been identified during postmarketing use of Ketorolac Tromethamine ophthalmic solution 0.5% in clinical practice. Because they are reported voluntarily from a population of unknown size, estimates of frequency cannot be made. The reactions, which have been chosen for inclusion due to either their seriousness, frequency of reporting, possible causal connection to topical Ketorolac Tromethamine ophthalmic solution 0.5% or a combination of these factors, include bronchospasm or exacerbation of asthma, corneal erosion, corneal perforation, corneal thinning, and epithelial breakdown [see Warnings and Precautions (5.2, 5.4)].

USE IN SPECIFIC POPULATIONS

Pregnancy

Teratogenic Effects. Pregnancy Category C

Pregnancy Category C: Ketorolac Tromethamine, administered during organogenesis, was not teratogenic in rabbits and rats at oral doses of 3.6 mg/kg/day and 10 mg/kg/day, respectively. These doses are approximately 100 times and 250 times higher respectively than the maximum recommended human topical ophthalmic daily dose of 2 mg (5 mg/mL x 0.05 mL/drop, x 4  drops x 2 eyes) to affected eyes on a mg/kg basis. Additionally, when administered to rats after Day 17 of gestation at oral doses up to 1.5 mg/kg/day (approximately 40 times the typical human topical ophthalmic daily dose), Ketorolac Tromethamine resulted in dystocia and increased pup mortality. There are no adequate and well-controlled studies in pregnant women. Ketorolac Tromethamine ophthalmic solution should be used during pregnancy only if the potential benefit justifies the potential risk  to the fetus.


Nonteratogenic Effects: Because of the known effects of prostaglandin-inhibiting drugs on the fetal cardiovascular system (closure of the ductus arteriosus), the use of Ketorolac Tromethamine ophthalmic solution during late pregnancy should be avoided.

Nursing Mothers

Because many drugs are excreted in human milk, caution should be exercised when Ketorolac Tromethamine ophthalmic solution is administered to a nursing woman.

Pediatric Use

Safety and efficacy in pediatric patients below the age of 2 have not been established.

Geriatric Use

No overall clinical differences in safety or effectiveness have been observed between elderly and other adult patients.

Ketorolac Tromethamine Description

Ketorolac Tromethamine ophthalmic solution 0.5% is a member of the pyrrolo-­pyrrole group of nonsteroidal anti-inflammatory drugs (NSAIDs) for ophthalmic use. Its chemical name is (±)-5-Benzoyl-2, 3-dihydro-1H pyrrolizine-1-carboxylic acid compound with 2-amino-2-(hydroxymethyl)-1,3-propanediol (1:1) and it has the following structure:



Ketorolac Tromethamine ophthalmic solution is supplied as a sterile isotonic aqueous 0.5% solution, with a pH of 7.4. Ketorolac Tromethamine ophthalmic solution is a racemic mixture of R-(+) and S-(-)- Ketorolac Tromethamine. Ketorolac Tromethamine may exist in three crystal forms. All forms are equally soluble in water. The pKa of ketorolac is 3.5. This white to off-white crystalline substance discolors on prolonged exposure to light. The molecular weight of Ketorolac Tromethamine is 376.41. The osmolality of Ketorolac Tromethamine ophthalmic solution is 290 mOsmol/kg.


Each mL of Ketorolac Tromethamine ophthalmic solution contains: Active: Ketorolac Tromethamine USP 0.5%. Preservative: benzalkonium chloride solution (50%) NF 0.02%. Inactives: edetate disodium USP 0.1%; octoxynol 40; water for injection USP; sodium chloride USP; hydrochloric acid NF and/or sodium hydroxide NF to adjust the pH.

Ketorolac Tromethamine - Clinical Pharmacology

Mechanism of Action

Ketorolac Tromethamine is a nonsteroidal anti-inflammatory drug which, when administered systemically, has demonstrated analgesic, anti-inflammatory, and anti-pyretic activity. The mechanism of its action is thought to be due to its ability to inhibit prostaglandin biosynthesis.

Pharmacokinetics

Two drops of 0.5% Ketorolac Tromethamine ophthalmic solution instilled into the eyes of patients 12 hours and 1 hour prior to cataract extraction achieved a mean ketorolac concentration of 95 ng/mL in the aqueous humor of 8 of 9 eyes tested (range 40 to 170 ng/mL).



One drop of 0.5% Ketorolac Tromethamine ophthalmic solution was instilled into 1 eye and 1 drop of vehicle into the other eye TID in 26 healthy subjects. Five (5) of 26 subjects had detectable concentrations of ketorolac in their plasma (range 11 to 23 ng/mL) at Day 10 during topical ocular treatment. The range of concentrations following TID dosing of 0.5% Ketorolac Tromethamine ophthalmic solution are approximately 4 to 8% of the steady state mean minimum plasma concentration observed following four times daily oral administration of 10 mg ketorolac in humans (290 ± 70 ng/mL).

Nonclinical Toxicology

Carcinogenesis, Mutagenesis,Impairment of Fertility

Ketorolac Tromethamine was not carcinogenic in either rats given up to 5 mg/kg/day orally for 24 months or in mice given 2 mg/kg/day orally for 18 months. These doses are approximately 125 times and 50 times higher respectively than the maximum recommended human topical ophthalmic daily dose given as QID for itching to affected eyes on a mg/kg basis.

Ketorolac Tromethamine was not mutagenic in vitro in the Ames assay or in forward mutation assays. Similarly, it did not result in an in vitro increase in unscheduled DNA synthesis or an in vivo increase in chromosome breakage in mice. However, Ketorolac Tromethamine did result in an increased incidence in chromosomal aberrations in Chinese hamster ovary cells.


Ketorolac Tromethamine did not impair fertility when administered orally to male and female rats at doses up to 9 mg/kg/day and 16 mg/kg/day, respectively. These doses are respectively 225 and 400 times higher than the typical human topical ophthalmic daily dose.

Clinical Studies

Two controlled clinical studies showed that Ketorolac Tromethamine ophthalmic solution was significantly more effective than its vehicle in relieving ocular itching caused by seasonal allergic conjunctivitis.


Two controlled clinical studies showed that patients treated for two weeks with Ketorolac Tromethamine ophthalmic solution were less likely to have measurable signs of inflammation (cell and flare) than patients treated with its vehicle.


Results from clinical studies indicate that Ketorolac Tromethamine has no significant effect upon intraocular pressure; however, changes in intraocular pressure may occur following cataract surgery.

How Supplied/Storage and Handling

Ketorolac Tromethamine ophthalmic solution 0.5% is supplied sterile in white opaque LDPE dropper bottles with white opaque plug and sealed with gray pantone opaque pilfer-proof caps as follows:


3 mL in 5 mL bottle                                        NDC 47335-219-90

5 mL in 5 mL bottle                                        NDC 47335-220-90

10 mL in 10 mL bottle                                    NDC 47335-221-90


Store at 20° to 25°C (68° to 77°F); excursions permitted between 15° and 30°C (59° and 86°F) [see USP Controlled Room Temperature]. Protect from light.

Patient Counseling Information

Slow or Delayed Healing

Patients should be informed of the possibility that slow or delayed healing may occur while using nonsteroidal anti-inflammatory drugs (NSAIDs).

Avoiding Contamination of the Product

Patients should be instructed to avoid allowing the tip of the bottle to contact the eye or surrounding structures because this could cause the tip to become contaminated by common bacteria known to cause ocular infections. Serious damage to the eye and subsequent loss of vision may result from using contaminated solutions.


Also, to avoid the potential for cross-contamination, the patient should be advised to use one bottle for each eye following bilateral ocular surgery. The use of the same bottle of topical eye drops for both eyes following bilateral ocular surgery is not recommended.

Contact Lens Wear

Patients should be advised that Ketorolac Tromethamine ophthalmic solution should not be administered while wearing contact lenses.

Intercurrent Ocular Conditions

Patients should be advised that if they develop an intercurrent ocular condition (e.g., trauma or infection) or have ocular surgery, they should immediately seek their physician’s advice concerning the continued use of Ketorolac Tromethamine ophthalmic solution.

Concomitant Topical Ocular Therapy


Patients should be advised that if more than one topical ophthalmic medication is being used, the medicines should be administered at least 5 minutes apart.

Distributed by:
Sun Pharmaceutical Industries, Inc.
Cranbury, NJ 08512

PJPI0496
ISS. 11/2014

PACKAGE LABEL.PRINCIPAL DISPLAY PANEL - Label - 3 mL

NDC 47335-219-90
Ketorolac Tromethamine Ophthalmic Solution
0.5%
Rx only
3 mL


PACKAGE LABEL.PRINCIPAL DISPLAY PANEL -Carton- 3 mL

NDC 47335-219-90
Ketorolac Tromethamine Ophthalmic Solution
0.5%
FOR USE IN THE EYES ONLY
Rx only
3 mL
SUN PHARMA

PACKAGE LABEL.PRINCIPAL DISPLAY PANEL - Label -5 mL

NDC 47335-220-90
Ketorolac Tromethamine Ophthalmic Solution
0.5%
Rx only
5 mL


PACKAGE LABEL.PRINCIPAL DISPLAY PANEL -Carton -5 mL

NDC 47335-220-90
Ketorolac Tromethamine Ophthalmic Solution
0.5%
FOR USE IN THE EYES ONLY
Rx only
5 mL
SUN PHARMA

PACKAGE LABEL.PRINCIPAL DISPLAY PANEL -Label -10 mL

NDC 47335-221-90
Ketorolac Tromethamine Ophthalmic Solution
0.5%
Rx only
10 mL

PACKAGE LABEL.PRINCIPAL DISPLAY PANEL -Carton -10 mL

NDC 47335-221-90
Ketorolac Tromethamine Ophthalmic Solution
0.5%
FOR USE IN THE EYES ONLY
Rx only
10 mL
SUN PHARMA

Ketorolac Tromethamine 
Ketorolac Tromethamine solution/ drops
Product Information
Product Type HUMAN PRESCRIPTION DRUG LABEL Item Code (Source) NDC:47335-219
Route of Administration OPHTHALMIC DEA Schedule     
Active Ingredient/Active Moiety
Ingredient Name Basis of Strength Strength
Ketorolac Tromethamine (KETOROLAC) Ketorolac Tromethamine 5 mg  in 1 mL
Inactive Ingredients
Ingredient Name Strength
BENZALKONIUM CHLORIDE  
EDETATE DISODIUM  
OCTOXYNOL-40  
SODIUM CHLORIDE  
HYDROCHLORIC ACID  
SODIUM HYDROXIDE  
WATER  
Packaging
# Item Code Package Description
1 NDC:47335-219-90 1 BOTTLE, DROPPER in 1 CARTON
1 3 mL in 1 BOTTLE, DROPPER
Marketing Information
Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date
ANDA ANDA090017 12/15/2014
Ketorolac Tromethamine 
Ketorolac Tromethamine solution/ drops
Product Information
Product Type HUMAN PRESCRIPTION DRUG LABEL Item Code (Source) NDC:47335-220
Route of Administration OPHTHALMIC DEA Schedule     
Active Ingredient/Active Moiety
Ingredient Name Basis of Strength Strength
Ketorolac Tromethamine (KETOROLAC) Ketorolac Tromethamine 5 mg  in 1 mL
Inactive Ingredients
Ingredient Name Strength
BENZALKONIUM CHLORIDE  
EDETATE DISODIUM  
OCTOXYNOL-40  
SODIUM CHLORIDE  
HYDROCHLORIC ACID  
SODIUM HYDROXIDE  
WATER  
Packaging
# Item Code Package Description
1 NDC:47335-220-90 1 BOTTLE, DROPPER in 1 CARTON
1 5 mL in 1 BOTTLE, DROPPER
Marketing Information
Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date
ANDA ANDA090017 12/15/2014
Ketorolac Tromethamine 
Ketorolac Tromethamine solution/ drops
Product Information
Product Type HUMAN PRESCRIPTION DRUG LABEL Item Code (Source) NDC:47335-221
Route of Administration OPHTHALMIC DEA Schedule     
Active Ingredient/Active Moiety
Ingredient Name Basis of Strength Strength
Ketorolac Tromethamine (KETOROLAC) Ketorolac Tromethamine 5 mg  in 1 mL
Inactive Ingredients
Ingredient Name Strength
BENZALKONIUM CHLORIDE  
EDETATE DISODIUM  
OCTOXYNOL-40  
SODIUM CHLORIDE  
HYDROCHLORIC ACID  
SODIUM HYDROXIDE  
WATER  
Packaging
# Item Code Package Description
1 NDC:47335-221-90 1 BOTTLE, DROPPER in 1 CARTON
1 10 mL in 1 BOTTLE, DROPPER
Marketing Information
Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date
ANDA ANDA090017 12/15/2014
Labeler - Sun Pharma Global FZE (864347344)
Establishment
Name Address ID/FEI Operations
Sun Pharmaceutical Industries Limited 725959238 ANALYSIS(47335-219), MANUFACTURE(47335-219)
Revised: 12/2014
 
Sun Pharma Global FZE
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