• Ketorolac injection, Fresenius Kabi
  30 mg/mL, 1 mL vial, 25 count (NDC 63323-0162-01)

• • BD RX is now part of Fresenius Kabi.²
  • Fresenius Kabi has ketorolac injection available.³
  • Pfizer has ketorolac injection on back order due to manufacturing delays.⁴
  • Sagent states the reason for the shortage is manufacturing delay.⁵
  • West-Ward is not actively marketing ketorolac injection.⁶
  • Ben Venue closed its plant in Bedford, Ohio in July 2014.⁷
  • FDA imposed an import ban in mid-2013 on several Wockhardt products including ketorolac.⁸
  • Sprix Nasal Spray is not affected by this shortage.⁹

• Ketorolac injection, Amphastar
  30 mg/mL, 1 mL vial, 10 count (NDC 00548-9021-00)

Estimated Resupply Dates

• • Sagent has ketorolac 15 mg/mL 1 mL vials, 30 mg/mL 1 mL vials, and 30 mg/mL 2 mL vials for intramuscular injection on back order and the company cannot estimate a release date.⁵
  • Fresenius Kabi has ketorolac 30 mg/mL 1 mL vials on back order and the company estimates a release date of mid-July 2017.³
  • Pfizer has ketorolac 30 mg/mL 2 mL Carpuject syringes for intramuscular use on back order and the company estimates a release date of fourth quarter 2017.⁴
    

Implications for Patient Care

• Ketorolac is a nonsteroidal anti-inflammatory drug labeled for use in adults with moderate to severe acute pain who require short-term analgesia at the opioid level, typically following surgery.10 Ketorolac can be used alone, or in combination with opioid analgesics. Ketorolac is useful in situations where opioids are contraindicated or to reduce opioid dosage requirements when used in combination with opioids. Total duration of ketorolac given intravenous, intramuscular, or orally should not exceed 5 days due to the increased frequency and severity of adverse reactions. Ketorolac, given intramuscularly, is used off-label for the management of migraine.^11-12

Safety

• Dosage recommendations and administration times vary significantly between alternative agents. Patient harm can occur if these agents are used erroneously. Use extra caution when switching to alternative agents.^10,13-15

Alternative Agents & Management

• • No single agent can be substituted for ketorolac injection. The choice of alternative agent must be patient-specific, procedure-specific, and based on the clinical situation and other comorbid conditions. Utilize stakeholder clinicians to help make specific plans for individual patient populations.
  • Tables 1 and 2 summarize the differences between some potential alternatives to ketorolac for acute pain. Injectable diclofenac was recently approved by the FDA (December 2014) but the product is not currently available and not included in the tables.^10-15,4
  • During this shortage, ensure appropriate pain control and explore all therapeutic modalities. Utilize oral and rectal medications whenever possible.
  Table 1. Comparison of Select Non-Opioid Injectable Agents Used for Acute Pain^10-13,15-16 

  Medication	Description	Labeled Indication for Adults	How Supplied	Storage and Handling	Dose Preparation
  Ketorolac	Nonsteroidal anti-inflammatory (NSAID)	Moderate to severe pain that requires analgesia at opioid level; for short-term use only (< 5 days).	Injection: 15 mg in1 mL single-dose vial or syringe 30 mg in 1 mL single-dose vial or syringe 60 mg in 2 mL single-dose vial (30 mg/mL) Intranasal: 15.75 mg/spray Oral: 10 mg tablet	Store at room temperature (20-25 degrees C). Protect from light.	Withdraw the correct dose from vial into appropriate sterile syringe. Discard unused portion of single-dose vials. To avoid precipitation, do not mix ketorolac with morphine, meperidine, promethazine, or hydroxyzine in a syringe or other small volume. An intravenous bolus is given over 15 seconds.
  Ibuprofen (Caldolor) Cumberland Pharmaceuticals	Nonsteroidal anti-inflammatory	Mild to moderate pain. Moderate to severe pain with adjunctive opioids. Fever reduction.	Injection: 100 mg/mL 8 mL single-dose vial Oral: multiple presentations	Diluted solutions stable for <24 hours at room temperature. Store unopened vials at room temperature (20-25 degrees C).	Prior to administration, dilute to < 4mg/mL concentration, in 0.9% sodium chloride injection, 5% dextrose injection, or lactated Ringer's injection. Infusion time must be no less than 30 minutes.
  Acetaminophen (Ofirmev) Cadence Pharmaceuticals	Non-salicylate, non-opioid agent with antipyretic and analgesic effects	Mild to moderate pain. Moderate to severe pain with adjunctive opioids. Fever reduction.	Injection: 10 mg/mL 100 mL single use vial Oral: multiple presentations Rectal: multiple presentations	Store at room temperature (20-25 degrees C). Do not refrigerate or freeze. Use within 6 hours of opening the vial.	Do not mix or administer with other medications. Doses of 1000 mg may be given undiluted from original vial using vented IV set. Doses of <1000 mg must be withdrawn from original vial and placed in a separate empty container (glass bottle, plastic IV container, or syringe) prior to administration. Discard unused portion of vial. Infusion time is 15 minutes.

  
  Table 2. Comparison of Non-Opioid Injectable Agents Used for Acute Pain: Pharmacokinetic Parameters, Warnings and Contraindications^10-16
    

  Medication	Mean Volume of Distribution	Mean Half-life	Protein binding	Black Box Warnings	Contraindications
  Ketorolac	Intravenous: 0.21 L/kg Intramuscular: 0.18 L/kg	Racemate: 5.6 hours (intravenous) 5.3 hours (oral, intramuscular) 4.8 hours (intranasal)	99%	Not for minor or chronic pain Not for pediatric patients Risk of potentially fatal GI bleeding or perforation; elderly patients at increased risk Increased risk of potentially fatal cardiovascular thrombotic events, myocardial infarction, and stroke Peri-operative pain in CABG surgery Renal toxicity risk Bleeding risk due to platelet function inhibition Not for use prior to major surgery Risk of hypersensitivity reactions; must have measures available to treat at first-dose administration Contains alcohol, do not administer via intrathecal or epidural routes Risk of fetal harm if used during labor and delivery Risk to nursing neonate if used by mother Risk of additive adverse events if used with other NSAIDs Reduce dose in patients >65 years old, patients weighing <50 kg, or patients with elevated serum creatinine. Do not exceed total daily dose of 60 mg injectable ketorolac Do not exceed 5 days (combined duration, any route)	History of allergic reaction to ketorolac, aspirin, or any other NSAID Active peptic ulcer disease Recent GI bleeding or perforation History of GI bleeding or peptic ulcer disease Peri-operative pain in CABG surgery Advanced renal impairment Patients at risk of renal failure resulting from volume depletion Cerebrovascular bleeding (suspected or confirmed) Hemorrhagic diathesis Incomplete hemostasis Patients with high risk of bleeding Prior to any major surgery Intrathecal or epidural administration During labor and delivery Nursing mothers Concomitant use with aspirin or other NSAIDs Concomitant use with probenecid or pentoxifylline
  Ibuprofen (Caldolor)	Not available	2.4 hours	>99%	Increased risk of potentially fatal cardiovascular thrombotic events, myocardial infarction, and stroke; do not use for CABG surgery peri-operative pain Risk of potentially fatal GI bleeding, ulceration, or perforation; elderly patients at increased risk	Known hypersensitivity to ibuprofen History of allergic reactions, asthma, or urticaria with aspirin or any other NSAID Peri-operative pain in CABG surgery
  Acetaminophen (Ofirmev)	Intravenous: 0.8 L/kg	2.4 hours	10 to 25%	Risk of medication errors and hepatotoxicity. Dosing errors could lead to accidental death and overdose. Risk of acute liver failure, liver transplant, or death	Known hypersensitivity to acetaminophen or excipients Severe hepatic impairment or active liver disease

   

References

• 1. Amphastar (personal communications). October 4, 2016; and January 9, 2017.
  2. BD Rx (personal communications). November 11, 2015; and February 4, 2016.
  3. Fresenius Kabi (personal communications). February 2, 11, 18, and 24, March 11, 18, and 31, May 6 and 20, June 30, July 6, August 6, September 10, October 8, November 4, December 11, 2015; January 20, February 5 and 18, March 7, May 13 and 23, June 8 and 30, July 29, September 6, October 4 and 27, 2016; January 28, February 20, March 21, June 2 and 20, and July 7, 2017.
  4. Pfizer (personal communications and website). February 10 and 24, March 2, 13, and 20, April 1 and 7, May 11 and 22, July 2 and 27, September 15, October 12, November 12, December 11, 2015; January 26, February 5, 22, and 25, March 7, April 28, May 20, June 16 and 23, July 7, August 2, September 6, October 4, November 6, 2016; January 30, February 23, March 24, June 2, 5, and 23, and July 7, 2017.
  5. Sagent (personal communications). February 9, 19, and 26, March 12, 20, and 27, April 2, May 7 and 21, July 2 and 30, September 10, October 8, November 5, December 10, 2015; January 21, February 4 and 18, March 7, April 28, May 19 and 26, June 16, July 7 and 29, September 6, October 4, November 3, 2016; January 27, February 23, March 23, June 1 and 22, and July 7, 2017.
  6. West-Ward (personal communications). January 29, February 18, March 11, April 2, and May 6, June 24, July 29, and September 1, 2015; January 27 and March 29, 2016.
  7. Ben Venue (personal communications). August 5, 2014.
  8. Wockhardt (personal communications). December 9, 2013.
  9. Egalet Corporation (personal communications). April 1, 2015.
  10. Hospira. Ketorolac tromethamine injection solution [product information]. Lake Forest, IL: Hospira 2014.
  11. Anon, editor. Drugdex System. Micromedex 2.0 [internet database]. Greenwood Village, CO: Truven Health Analytics; 2015.
  12. Wickersham RM, Novak KK, managing eds., editors. Drug Facts and Comparisons (Facts & Comparisons eAnswers). St. Louis, MO: Wolters Kluwer Health, Inc.; 2015.
  13. Cumberland Pharmaceuticals Inc. Caldolor (ibuprofen) Injection, for intravenous use [product information]. Nashville, TN: Cumberland Pharmaceuticals Inc.; 2014.
  14. Hospira. Dyloject (diclofenac sodium) Injection [product information]. Lake Forest, IL: Hospira 2014.
  15. Cadence Pharmaceuticals. Ofirmev (acetaminophen) Injection [product information]. San Diego, CA: Cadence Pharmaceuticals, Inc.; 2010.
  16. Regency Therapeutics. Sprix (ketorolac tromethamine) nasal spray [product information]. Shirley, NY: American Regent 2014.