1.04.2013

Toradol in the spotlight

Toradol is one of my favorite drugs to give in the Emergency room. It works great and is non-narcotic. 

Nightline and ABC news had a story out last night about the use of Toradol in college football locker rooms. Toradol is a NSAID pain reliever -- think of it as a prescription strength injectable super ibuprofen that works fast and relieves pain without the narcotic side effects. 

We use Toradol -- or Keterolac -- all the time in the emergency room. Kidney stone pain -- which some of my patients report as worse than child birth -- responds particularly well to Toradol. 

It is also a great medication to use after a orthopedic surgery to reduce postsurgical pain and inflammation and get patients up and out of bed. 

NSAID (Non-steriodal Anti-Inflamatory) drugs work by inhibiting the production of prostaglandin which is a key fuel for pain receptors. Prostaglandins works locally rather than systemically like a hormone, and they do different things in different parts of your body at different times. So it may be a pain and inflammation mediator at your knee, and it may be regulating platelet aggregation or reducing stomach acid someplace else. If you take a drug to inhibit prostaglandins all over your body, you could get several unintended side effects. 

The most common side effects seen from long term NSAID use are gastrointestinal and renal. These drugs are mostly cleared by the kidneys and prostaglandins have a role to play in kidney function. In fact we often check the kidney function tests of patients BEFORE we give Toradol in the hospital. You shouldn't give it to patients with fluid imbalances, congestive heart failure or impaired kidney function. 

Except for Aspirin, NSAIDs increase your risk for heart attack and stroke. This is because they increase platelet aggregation, making it more likely for you to form a clot. Aspirin, on the other hand, decreases platelet aggregation and thus protects us from heart attack and stroke. 

Do NSAIDs cause heart attacks? Here's what  has to say:

"So far, there is no evidence that any of the NSAIDs causeheart attacks in otherwise normal hearts. More likely, these drugs act by increasing the stickiness of platelets, so that in patients who have pre-existing coronary artery plaques that rupture, the platelets are somewhat more likely to occlude the artery in patients on NSAIDs than in patients not on NSAIDS. However, in patients who have plaques waiting to rupture, a heart attack is reasonably likely whether they are taking NSAIDs or not. Statistically, the risk is somewhat increased on NSAIDs. We must remember, however, that fundamentally the risk of heart attack is determined by the sum of many things - age, weight, exercise levels, blood pressure, lipid levels, diabetes, and smoking. The use of NSAIDs, apparently, tweaks that risk somewhat."

So, for the purposes of the lawsuit, this football player is alleging that he was perfectly healthy before he gets a shot of Toradol, then has a heart attack. That's going to be hard to prove in court. On the other hand, he may be able to prove that the team doc was using it without taking into consideration - or explaining - the potential risks of the drug. 

Moreover, prior risk factors for heart disease is something this person may or may not have been screened for. At this level of athletics, team doctors may be doing all sorts of baseline medical screening -- or they may just be doping the kids up assuming that they are perfect pictures of health when they walk through the door. 

If a healthy looking 20 year old came through with a kidney stone, I wouldn't hesitated to tell the doctor that he needs a little Toradol to make him feel better. That said, I've me some healthly looking 20 year olds with all sorts of medical history that was not obvious at first glance. 

Finally, I'd like to know is how often players were getting injected, and whether they were popping Advil on the side. 

Meanwhile, when you come in with your kidney stone, I'll be sure to have the Toradol ready. 

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