CLINICAL

Ketorolac versus Ibuprofen: A Simple Cost-Efficacy Com parison for Dental Use

i Ben Balevi, B. Eng., DDS

As dentists, we are regularly for its analgesic qualities than for its On a fractional cost compari inundated with promo anti-inflammatory activity. Two son, Motrin (400 mg tablets) is 55 tional literature on the studies investigating the efficacy of per cent less expensive than ke newest dental therapies and prod a single dose of ketorolac (10 mg) torolac. Even better value is found ucts. For the most part, this com following dental impaction surgery with generic ibuprofen (400 mg mercial marketing consists of large, have demonstrated it to be a supe tablets) and OTC ibuprofen, with four-color, glossy spreads, which rior analgesic to the acetamino fractional costs of 41 per cent and typically summarize the efficacy of phen and codeine combination an 21 per cent respectively. Hence, a product in one or two lines (i.e., algesic Tylenol 3.67 The second the cost to the patient of a typical the slogan), complemented by study also included ibuprofen (400 post dental surgery prescription of convincing graphs and photo mg)as one of the treatment groups. ibuprofen is one-half to one-fifth graphs. These marketing methods This second study revealed thatthe the cost of ketorolac. can be impressive — the recent clinical efficacy of ketorolac (10 For ketorolac to be cost-effective, introduction of ketorolac (Toradol) mg)versus ibuprofen (400 mg)was its significantly higher cost would is a case in point. statistically insignificant.7 have to be concomitant with a Ketorolac is being aggressively There is no doubt that ketorolac proven analgesic advantage over marketed to dentists as a "non-nar is an effective analgesic. However, ibuprofen. Asdiscussed, a search of cotic" analgesic that provides "nar for pain incurred during dental ex the scientific literature to date does cotic efficacy without narcotic traction, ketorolac and ibuprofen not support the premise that ketoro drawbacks." At first glance, this have been shown, scientifically, to lac is superior to ibuprofen for den promotional strategy gives the im be equally potent analgesics. The tal use. Therefore, it seems reason pression that until ketorolac came question that begs to be asked, able to conclude that ketorolac is on the scene, there was no other then, is:are the two drugs available notably less cost effective than "non-narcotic" alternative for the to the patient at a comparable cost? ibuprofen for the routine manage management of acute dental pain. Table I compares the costs of ment of post dental extraction pain. This, however, is not the case. ketorolac (10 mg) with the costs of Ketorolac may well be a more Ibuprofen (e.g., Motrin, Advil, three available types of ibuprofen. potent analgesic than ibuprofen. and Mediprin) is also a "non-nar The comparison is based on the However, even if this is the case, cotic" analgesic with proven "nar cost to the patient of a typical post ketorolac's advantage is not real cotic efficacy," and it has been dental surgery prescription of 25 ized when it is used to control post used for managing moderate to pills for each drug. The OTC (over- dental extraction pain. In other moderately severe dental pain for the-counter) form of ibuprofen is words, as painful as dental surgery well over a decade. Ibuprofen is a only available in 200 mg tablets. may seem, it may not be painful NSAID (nonsteroidal anti-inflam Therefore, a box of 50 pills is con enough to take advantage of ke matory drug)with both anti-inflam sidered to be equivalent to 25 pills torolac's superior analgesic prop matory and analgesic properties.1 of 400 mg ibuprofen. Exceptforthe erties, if these properties actually Many studies have confirmed its cost of OTC ibuprofen, all other exist. efficacy for relieving post dental costs include the pharmacy's pro I do not wish to totally discount surgery pain.'"5 ketorolac's usefulness as a dental l.inuary/ fessional fees. As such, these costs Janvier Ketorolac is also classified as an will vary somewhat from city to city analgesic. On the contrary, the 1994 Vol. 60 NSAID, but it is considered more and province to province. drug is a welcome addition to our No. 1

31 analgesic armamentarium. For in Table I stance, ketorolac is available for Cost Comparison of Ketorolac and Ibuprofen intramuscular injection, and is the only true alternative to narcotics AnalgesicType Total Cost Cost per Dose Fractional via this route. A single intramuscu to Patient($)• (^Tablet)" Cosf lar injection (I.M.) dose of ketoro lac (30 mg) has been shown to be Ketorolac as effective as a 100 mg I.M. injec Toradci* 10mg (25 tablets) 2750 1.10 1.00 tion of meperidine (Demerol) for controlling post oral surgery Ibuprofen pain.89 Motrin9 400 mg (25 tablets) 15.00 0.60 0.55 On top of its I.M. advantage, ketorolac's oral tablet form could Generic 400mg(25tablets) 1125 0.45 0.41 be used as a back-up in those few OTC 200 mg3 (50 pills) 6.00 024 021 cases where patients do not re spond to the normally prescribed a. Costs given bya Toronto areapharmacy. These costs indude thepharmacy's professional fees. analgesics. However, ketorolac, as As such, thesespecific costs may vary from city todtyandprovince toprovince. well as other NSAIDs, including b.Calculated bydividing thetotal cost topatient by25pills. Theamount ofpills dispensed affects ibuprofen, should not be adminis this value. tered to patients presenting with a c.Calculated bydividing thecostofeachanalgesic bythecostofketorolac. Thevaluerepresents medical history of ASA allergy or thefractional costofeachanalgesic tothatofketorolac. serious gastrointestinal bleeding d. Over-the-counter (OTC) ibuprofen isonly available in200mg pills. Two pills ofOTC areequiva due to an underlying peptic ulcer lent toone Ibuprofen (400 mg) pill. Aboxof50OTC pills isequivalent todispensing 25Ibuprofen disease. (400 mg) pills. Nevertheless, at this time it is simply not cost effective to rou acetaminophen and acetaminophen- tinely prescribe ketorolac (oral) for Dr. Ben Balevi is affiliated with the Oril- codeine combination in postoperative acute post dental surgery pain. This lia Soldiers' Memorial Hospital and the oral surgery pain. Pharmacotherapy applies to all dental surgical proce Huronia Regional Centre. 10:94S-105, 1990. dures with the possible exception Reprint requests to: Dr. Ben Balevi. 605 8. Brown, C.R.The analgesic efficacyof of dental impaction surgery, as the Finch Ave. W. Suite 923, Toronto, ON ketorolac tromethamine by oral and in intensity of post surgical pain may M2R 1P1. tramuscular administration in single- be significantly higher in these dose studies on various postoperative cases. As such, more research is pain states. Paper delivered at the fifth World Congress on Pain. Hamburg, needed on ketorolac's efficacy, References Germany, Aug. 4, 1987. particularly with different oral dos 1. Cooper, S.A.Fivestudies on ibuprofen 9. Brown, C.R., Moodie, I.E., Evans, S.A., age regimens, before it can be rec tor postsurgical dental pain. Am I Med et al. Efficacy of intramuscular (I.M.) ke ommended for routine use in the 77(1A):70-77, 1984. torolac and meperidine in pain follow management of dental pain. 2. Cooper, S.A. The relative efficacy of ing major oral surgery, (abstr) Clin Phar Ketorolac is an example of how ibuprofen in dental pain. Compend macol Ther 43:161, 1988. vigorous marketing can make a Contin Educ Dent 7:579-597, 1986 more costly, but not necessarily su 3. lain. A.K., Ryan, J.R.,McMahon. F.G. perior analgesic, look more attrac et al. Analgesic efficacy of low-dose tive compared to what is already ibuprofen in dental extraction pain. available. It is much easier to cen Pharmacotherapy 6:318-322. 1986. tre our attention on a visually pleas 4. Forbes, ).A., Barkaszi, B.A., Ragland, ing product advertisement than on R.N. et al. Analgesic effect of fendosal, a dry scientific study. But as den ibuprofen and aspirin in postoperative tists, we have an obligation to our oral surgery pain. Pharmacotherapy patients to evaluate the advantages 4:385-391, 1984. of new therapies as they become 5. Mehlisch, D.R., Sollectio. W.A.. Hel- available. Indoing so, it is impera frick) |.F. etal. Muticenter clinical trial of tive that we base our judgements ibuprofen and acetaminophen in the treatment of postoperative dental pain. on the objective findings of prop jADA 121:257-263, 1990. erly performed scientific investiga tions rather than on subjective mar 6. Forbes, ).A., Butterwonh, G.A., Buch- field, W.H. et al. Evaluation of ketorolac, keting or a clinician's perception. aspirin and an acetaminophen-codeine New dental therapies should also combination in postoperative oral sur be judged on their cost effective gery pain. Pharmacotherapy10:77S-93. I.inu.iry/ 1990. l.invn-i ness to the patient. Otherwise, it 1994 would be a disservice to our pa 7. Forbes, j.A.. Kehm. C.J., Gordin. CD. Vol. dO No. I tients. • et al. Evaluation of ketorolac, ibuprofen,

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