Ketorolac vs. naproxen (Aleve)

• Ketorolac and naproxen are nonsteroidal anti-inflammatory drugs (NSAIDs) used to treat varying levels of pain.
• Ketorolac is used for short-term management (up to 5 days) of moderately severe acute pain that otherwise would require narcotics.
• Naproxen is used to treat mild to moderate pain, inflammation, and fever.
• Brand names for ketorolac include Acuvail, Acular LS, Omidria, and Sprix. The Toradol brand of ketorolac has been discontinued in the U.S.
• Brand names for naproxen include Aleve, Anaprox DS, and Naprosyn.
• Naproxen is available over-the-counter (OTC) and as a generic.
• Side effects of ketorolac and naproxen that are similar include rash, ringing in the ears, headaches, dizziness, drowsiness, abdominal pain, nausea, diarrhea, constipation, heartburn, and fluid retention.
• Side effects of ketorolac that are different from naproxen include indigestion and itching.
• Side effects of naproxen that are different from ketorolac include shortness of breath.

Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) used for short-term (up to 5 days) treatment of moderately severe acute pain that would otherwise require narcotics. Ketorolac is not used for minor or chronic painful conditions. Other NSAIDs include naproxen (Aleve, Naprosyn) and ibuprofen (Advil, Motrin), but ketorolac is better than other NSAIDs in reducing pain from both inflammatory and non-inflammatory causes. Ketorolac reduces the production of chemicals that cells of the immune system make that cause the redness, fever, and pain of inflammation (prostaglandins) and that are thought to play a role in the production of non-inflammatory pain. Ketorolac does this by blocking cyclooxygenase 1 and 2, the enzymes that cells use to make prostaglandins, which results in a reduction in pain and inflammation, and signs and symptoms of redness, swelling, fever, and pain.

Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) used to treat mild to moderate pain, inflammation, and fever. Other NSAIDs include ibuprofen (Advil, Motrin), indomethacin (Indocin), nabumetone (Relafen) and several others. These drugs are used for the management of mild to moderate pain, fever, and inflammation. They work by reducing the levels of prostaglandins, chemicals that are responsible for pain, fever, and inflammation. Naproxen blocks the enzyme that makes prostaglandins (cyclooxygenase), resulting in lower concentrations of prostaglandins. As a consequence, inflammation, pain, and fever are reduced.

Ketorolac

Common side effects from ketorolac include:

• Rash
• Ringing in the ears
• Headaches
• Dizziness
• Drowsiness
• Abdominal pain
• Nausea
• Diarrhea
• Constipation
• Indigestion
• Itching
• Heartburn
• Fluid retention

Rare side effects of ketorolac include:

• Abnormal thinking
• Serious allergic reactions
• Blurred vision
• Bronchospasm
• Jaundice
• Depression
• Difficulty concentrating
• Taste abnormality
• Euphoria
• Hemolytic-uremic syndrome
• High potassium blood levels
• Low sodium levels

Serious side effects of ketorolac include:

• Stomach ulcers
• Intestinal bleeding
• Reduced kidney function
• Liver failure

Other serious adverse events include:

• NSAIDs reduce the ability of blood to clot and therefore increase bleeding after an injury. Ketorolac may cause ulcers and bleeding in the stomach and intestines, particularly with use for more than five days. Sometimes, stomach ulceration and intestinal bleeding can occur without any abdominal pain. Sometimes, the only signs or symptoms of bleeding may be:
  • Black tarry stools
  • Weakness
  • Dizziness upon standing (orthostatic hypotension)
• NSAIDs reduce the flow of blood to the kidneys and impair function of the kidneys. The impairment is most likely to occur in patients with preexisting impairment of kidney function or congestive heart failure, and use of NSAIDs in these patients should be done cautiously.
• Liver failure has also been associated with ketorolac.
• People who are allergic to aspirin and other NSAIDs should not use ketorolac.
• Individuals with asthma or nasal polyps are more likely to experience allergic reactions to NSAIDs.

Naproxen

The most common side effects from naproxen are:

• Rash
• Ringing in the ears
• Headaches
• Dizziness
• Drowsiness,
• Abdominal pain
• Nausea
• Diarrhea
• Constipation
• Heartburn
• Fluid retention
• Shortness of breath

Other important side effects include:

• Fluid retention
• Blood clots
• Heart attacks
• Hypertension
• Heart failure

Ketorolac

• Treatment should begin with ketorolac injection.
• Tablets are used only if treatment is continued after patients begin to eat and drink.
• The total duration of therapy should not exceed 5 days because of the potential for gastrointestinal bleeding and other side effects.
• The recommended adult intravenous single dose is 15 to 60 mg.
• Multiple intravenous doses of 15 or 30 mg every 6 hours, not to exceed 60 or 120 mg a day, also may be used.
• Following intravenous therapy, the recommended dose is 1 (10 mg) or 2 (20 mg) tablets initially followed by 1 (10 mg) tablet every 4 to 6 hours, not to exceed 40 mg daily.
• The smaller dose is used for patients with poor kidney function or those older than 65 years.
• Oral ketorolac is not approved for individuals less than 17 years of age.

Naproxen

The usual adult dose for pain is 250 mg every 6 to 8 hours or 500 mg twice daily using regular naproxen tablets. The usual dose for Naprelan controlled release tablets is 750 to 1000 mg given once daily. For EC-Naprosyn, the usual dose is 375 to 500 mg twice daily.

Naproxen should be given with food to reduce upset stomach. The dose for rheumatoid arthritis, osteoarthritis, or ankylosing spondylitis is 500 to 1000 mg every 12 hours. Dysmenorrhea is treated with 250 mg every 6 to 8 hours after an initial dose of 500 mg.

Ketorolac

• Probenecid (Benemid) should not be combined with ketorolac because it reduces the elimination of ketorolac by the kidneys. This may lead to increased levels of ketorolac in the body and increased side effects from ketorolac.
• Ketorolac may increase the blood levels of lithium (Eskalith, Lithobid) by reducing the function of the kidneys to eliminate lithium. Increased levels of lithium may lead to lithium toxicity.
• Concomitant use of ketorolac and angiotensin converting enzyme (ACE) inhibitors may reduce the function of the kidneys.
• Individuals taking oral blood thinners or anticoagulants -- for example, warfarin (Coumadin, Jantoven) -- should avoid ketorolac because ketorolac also thins the blood, and excessive blood thinning may lead to bleeding.

Naproxen

Naproxen is associated with several suspected or probable interactions that affect the action of other drugs. The following examples are the most common suspected interactions.

• Naproxen may increase the blood levels of lithium (Eskalith, Lithobid) by reducing the excretion of lithium by the kidneys. Increased levels of lithium may lead to lithium toxicity.
• Naproxen may reduce the blood pressure-lowering effects of blood pressure medications. This may occur because prostaglandins play a role in the regulation of blood pressure.
• When naproxen is used in combination with methotrexate (Rheumatrex, Trexall) or aminoglycosides (for example, gentamicin), the blood levels of the methotrexate or aminoglycoside may increase, presumably because the elimination of these drugs from the body is reduced. This may lead to more methotrexate or aminoglycoside-related side effects.
• Individuals taking anticoagulants -- for example, warfarin (Coumadin, Jantoven) -- should avoid naproxen because naproxen also thins the blood, and excessive blood thinning may lead to bleeding.
• Naproxen increases the negative effect of cyclosporine on kidney function and reduces the effect of furosemide (Lasix) and thiazide diuretics because of prostaglandin inhibition.
• Naproxen should be avoided by patients with a history of asthma attacks, hives or other allergic reactions to aspirin or other NSAIDs.
• Taking aspirin with naproxen may cause an increased risk for developing an ulcer.
• Persons who have more than 3 alcoholic beverages per day may be at increased risk of developing stomach ulcers when taking naproxen or other NSAIDs.

Ketorolac

There are no adequate studies in pregnant women. Ketorolac should only be used during pregnancy if the potential benefit justifies the potential risk to the fetus. NSAIDs may cause cardiovascular side effects during late pregnancy.

Ketorolac should not be used by nursing mothers because it is excreted in breast milk.

Naproxen

NSAIDs may cause a fetal birth defect called ductus arteriosus (early closure of two major blood vessels of the heart and lung) in the third trimester of pregnancy. Therefore, NSAIDs should be avoided during this last part of pregnancy.

A small amount of naproxen is excreted in breast milk. Because the concentration in breast milk is low, breastfeeding while taking naproxen probably is not harmful to the infant.