incision administration, but that's only because the formulators didn't
study its pre-operative effectiveness. (Many clinicians administer
ketorolac pre-operatively anyway.) Caldolor and Dyloject, on the
other hand, were both tested for pre-incision efficacy, so their labels
say they can be used both pre- and post-operatively. You can use an IV
NSAID as an around-the-clock drug from pre-incision until the time
the patient doesn't have IV access. Or you can use one as a PRN — so
when a patient has a spike in pain during recovery, you administer it
instead of opioids. Again, it's up to the clinician.
Which is best?
There's never been a study comparing the 3 head to head, so no one
can point to clear evidence that one is better than another. They're all
COX inhibitors, although there are slight differences in the relative
balance of COX-1 and COX-2, as well as some other minor differ-
ences. Unlike the other two, ibuprofen has to be mixed before it's
administered; you can just bolus ketorolac and diclofenac. Ibuprofen
also has to be infused over a longer period of time, because it can
burn a little if you give it too rapidly. Another small difference:
Ketorolac administration is limited to 5 days. The others have no time
limitations.
There are also differences in price. Ketorolac is generic, so it's very
inexpensive. But the others are reasonably priced, too.
Any downsides?
Last summer, the FDA issued a safety communication, strengthening
warnings about the potential role of NSAIDs in cardiovascular events
(see "The Link Between NSAIDs and Cardiovascular Issues" on page
43), but it's yet to be determined whether short-term use poses any sig-
nificant danger, particularly in patients with no significant cardiovascu-
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