Ketorolac

For many people with migraine, it can be difficult to find a treatment that is effective and reliable, and information on how medications compare to one another is lacking. A new study draws data from nearly 300,000 people using a smartphone app to help people make decisions about their medications. The study found that certain migraine medications like triptans, ergots and anti-emetics may be two to five times more effective than ibuprofen for treating migraine attacks, according to new research. For many people with migraine, it can be difficult to find a treatment that is effective and reliable, and information on how medications compare to one another is lacking. A new study draws data from nearly 300,000 people using a smartphone app to help people make decisions about their medications. The study found that certain migraine medications like triptans, ergots and anti-emetics may be two to five times more effective than ibuprofen for treating migraine attacks, according to new research published in the November 29, 2023, online issue of Neurology®, the medical journal of the American Academy of Neurology. Migraine attacks are characterized by intense throbbing head pain, sensitivity to light and sound, nausea or vomiting. Previous research has shown migraine can also be associated with cognitive issues. All of these symptoms may impact a person's quality of life and productivity. "There are many treatment options available to those with migraine. However, there is a lack of head-to-head comparisons of the effectiveness of these treatment options," said study author Chia-Chun Chiang, MD, of the Mayo Clinic in Rochester, Minnesota, and member of the American Academy of Neurology. "These results confirm that triptans should be considered earlier for treating migraine, rather than reserving their use for severe attacks." For the study, researchers included over 3 million migraine attacks from nearly 300,000 users that were self-reported by people using a smartphone app during a six-year period. The app allows users to monitor the frequency of migraine attacks, triggers, symptoms and medication effectiveness. For those migraine attacks, participants entered 4.7 million treatment attempts with various medications into the app. They recorded in the app whether a medication was helpful or not. Researchers then used that information to calculate the effectiveness of each drug compared to ibuprofen. Researchers looked at a total of 25 medications among seven drug classes. Different dosages of medication and formulas of each medication were combined in this analysis. The study found that the top three classes of medications more effective than ibuprofen were triptans, ergots and anti-emetics. Triptans were five times more effective than ibuprofen, ergots were three times more effective and anti-emetics were two and a half times more effective. When looking at individual medications, the top three were eletriptan which was six times more effective than ibuprofen, zolmitriptan which was five and a half times more effective and sumatriptan which was five times more effective. Researchers found that when using eletriptan, participants found it helpful 78% of the time. Zolmitriptan was helpful 74% of the time and sumatriptan was helpful 72% of the time. Ibuprofen was helpful 42% of the time. Researchers also looked at other groups of medication such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs other than ibuprofen were 94% more effective than ibuprofen. Participants found ketorolac helpful 62% of the time, indomethacin was helpful 57% of the time, and diclofenac was helpful 56% of the time. However, acetaminophen was helpful 37% of the time and found to be 17% less effective than ibuprofen when used for treating migraines. Additionally, a common combination of medications used to treat migraine, aspirin, acetaminophen and caffeine was also evaluated and found to be 69% more effective than ibuprofen. "For people whose acute migraine medication is not working for them, our hope is that this study shows that there are many alternatives that work for migraine, and we encourage people to talk with their doctors about how to treat this painful and debilitating condition," said Chiang. A limitation of the study was evaluations of medications could be influenced by a user's expectations of the medication or the dosage they took. Another limitation was that newer migraine medications, gepants and ditans, were not included in the study due to the low amount of data when the study was conducted and lack of availability in many countries. The study was supported by the Kanagawa University of Human Services.

MONDAY, July 10, 2023 -- Less than half of all children treated by emergency medical services receive the right amount of medication during out-of-hospital emergencies, a new study found. In some cases, these incorrect doses can have serious consequences. “If you don't give the appropriate dose of the anti-seizure medication for a patient with an ongoing seizure, the seizure will not stop,” said study co-author Dr. Sriram Ramgopal , an attending physician in emergency medicine at Ann & Robert H. Lurie Children's Hospital of Chicago. “The longer a patient is seizing, the higher risk they are of having complications from that seizure," he said. They might aspirate into their lungs and get pneumonia from that, or they might have respiratory depression. And of course, if a child is having a seizure and you give too much of a medication, since they're also sedatives, they can suppress the child's breathing.” Specifically, the study -- published July 10 in the journal Pediatrics -- found that in the nearly 1 million pediatric encounters examined, just 42.6% administrations of 10 commonly used medications followed national guidelines. Seizure and sedating medications like morphine were among some of those most often given in incorrect amounts -- with most deviations representing an underdose. Those with the lowest adherence to guidelines were diazepam (19.4%) and lorazepam (21.2%). Appropriate dosing was most common with the anti-inflammatory methylprednisone (75.1%); intramuscular epinephrine (67.9%), which is often given to treat anaphylaxis; and the pain reliever ketorolac (56.4%). Dr. Jennifer Anders is a pediatric emergency medicine specialist at Johns Hopkins Children’s Center in Baltimore. While she was aware that incorrect dosing outside the hospital was a problem, she didn’t realize just how grave the situation was until she read the study. “What I found really stunning about this work that they did was … just how pervasive and extensive the problem is,” Anders said. “Even knowing that this was a problem, it really knocked my socks off.” Researcher Ramgopal stressed that blame for these inaccuracies should not be put on EMS workers themselves. “I think when we wrote the paper, we were very clear that while we think dosing errors are a part of it, I don't think that's all of it,” he said. “The paramedics who are doing this have a complex job in front of them. Rather than assigning blame to anybody, I think the important thing is: What can we do to improve systems, to minimize the risk of errors?” For children, most medications are dosed out based on weight. While there are techniques for doing so, guessing someone’s weight with relative accuracy can be difficult. Plus, when EMS workers face the stress of treating a child in crisis all while riding in the back of a truck, doing math to determine how much medication is needed can prove quite challenging. “It is not uncommon to have people do an error by 10 times the dose if they've misplaced a decimal point when they're doing that math,” Anders said. To make matters more complicated, there is no national standard among paramedics for pediatric drug doses. “The protocols that EMS is following vary from region to region, so those protocols might call for different doses of medications,” Ramgopal said. He said more centralized EMS practices could help close the gap on incorrect dosing. Several states rely guidelines put forth by the National Association of State EMS Officials, but many have their own guidelines, or, in some places, no official practices at all. The EMS for Children Program is also working to give all U.S. emergency departments the necessary resources and guidelines to care for children. Ramgopal also mentioned a 2015 study in which paramedics were given color-coded, prefilled syringes as a possible way to reduce dosing errors. The strategy was found to be significantly effective. Anders noted that another study is now in the works. The Pediatric Emergency Care Applied Research Network is testing administration of seizure medication with only three size options for children instead of measuring out medication based on exact weight. She suspects such a method will soon be common practice. “What a lot of us that are very active in pediatric prehospital medicine, I think, foresee on the horizon is a move to less stringent standards for an exact weight-based dose and more kind of an estimated small, medium, large kind of dosing regimen to make things much simpler and take the math out of the work for EMS clinicians,” Anders said. Sources Sriram Ramgopal, MD, attending physician, emergency medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, and professor, pediatrics, Northwestern University Feinberg School of Medicine, Chicago Jennifer Anders, MD, pediatric emergency medicine specialist, Johns Hopkins Children’s Center, Baltimore Pediatrics , July 10, 2023 Posted July 2023