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Dexketoprofen trometamol is the tromethamine salt of (S)-(+)-2-(3-benzoylphenyl)propionic acid, which has analgesic, anti-inflammatory and antipyretic effects and belongs to the class of nonsteroidal anti-inflammatory drugs (NSAIDs).
Mechanism of action
The mechanism of action of NSAIDs is based on a decrease in prostaglandin synthesis by inhibiting cyclooxygenase activity. In particular, the conversion of arachidonic acid to cyclic endoperoxides PGG2 and PGH2 is inhibited, from which prostaglandins PGE1, PGE2, PGF2α, PGD2 are formed, as well as prostacyclin PGI2 and thromboxanes ThA2 and ThB2. In addition, inhibition of prostaglandin synthesis may affect other inflammatory mediators, such as kinins, which may also indirectly affect the main effect of the drug.
Pharmacodynamic effects
Dexketoprofen trometamol has been shown to inhibit cyclooxygenase-1 and cyclooxygenase-2 activity in laboratory animals and humans.
Clinical efficacy and safety
Clinical studies in various types of pain have demonstrated that dexketoprofen trometamol has a pronounced analgesic effect. The analgesic effect of dexketoprofen trometamol when administered intramuscularly and intravenously to patients with moderate to severe pain has been studied in various types of surgical pain (orthopedic and gynecological operations, abdominal operations), as well as in musculoskeletal pain (acute low back pain) and renal colic. During the studies, the analgesic effect of the drug began quickly and reached a maximum within the first 45 minutes.
The duration of analgesic effect after the use of 50 mg of dexketoprofen trometamol is usually 8 hours. Clinical studies have shown that the use of the drug allows for a significant reduction in the dose of opiates when used simultaneously for the purpose of relieving postoperative pain. When patients who were prescribed morphine administration using a patient-controlled analgesia device for the purpose of relieving postoperative pain were also prescribed dexketoprofen trometamol, they required significantly less morphine (by 30-45%) than patients who received placebo.
Pharmacokinetics.
Absorption
After intramuscular administration of dexketoprofen trometamol in humans, the maximum concentration is reached after approximately 20 minutes (10-45 minutes). It has been proven that with a single intramuscular or intravenous administration of 25-50 mg of the drug, the area under the AUC (concentration-time) curve is proportional to the dose.
Distribution
Similar to other drugs with a high degree of binding to plasma proteins (99%), the volume of distribution of dexketoprofen is on average 0.25 l/kg. The half-life is approximately 0.35 hours, and the half-life is 1-2.7 hours.
Pharmacokinetic studies of multiple administration of the drug have demonstrated that Cmax and AUC after the last intramuscular or intravenous administration do not differ from those after a single administration, indicating the absence of drug accumulation.
Biotransformation and excretion
Dexketoprofen is mainly metabolized by conjugation with glucuronic acid followed by renal excretion. After administration of dexketoprofen trometamol, only the S-(+) optical isomer is detected in the urine, indicating that there is no transformation of the drug into the R-(–) optical isomer in humans.
Elderly patients
After single and multiple doses, the exposure of healthy elderly volunteers (65 years and older) participating in the study was significantly higher (up to 55%) than in young volunteers, but there was no statistically significant difference in maximum concentration and time to reach it. The mean half-life increased (up to 48%) and the determined total clearance decreased.
Preclinical safety data
Like all NSAIDs, dexketoprofen can cause embryo or fetal death in animals by directly affecting its development or indirectly by damaging the gastrointestinal tract of the mother.
Indication
Symptomatic treatment of acute pain of moderate to severe intensity in cases where oral administration of the drug is inappropriate, for example, in postoperative pain, renal colic and low back pain.
Contraindication
Hypersensitivity to dexketoprofen, any other non-steroidal anti-inflammatory drug (NSAID) or to any of the excipients of the drug;
patients in whom the use of substances with similar effects, such as acetylsalicylic acid or other NSAIDs, provokes the development of attacks of bronchial asthma, bronchospasm, acute rhinitis, nasal polyps, the appearance of urticaria or angioedema;
if photoallergic or phototoxic reactions occurred during treatment with ketoprofen or fibrates;
history of gastrointestinal bleeding or perforation associated with NSAID therapy;
active peptic ulcer/gastrointestinal bleeding, or history of gastrointestinal bleeding, ulcers or perforations;
chronic dyspepsia;
bleeding in the active phase or increased bleeding;
Crohn's disease or nonspecific ulcerative colitis;
severe heart failure;
moderate or severe renal impairment (creatinine clearance ≤ 59 ml/min);
severe liver dysfunction (10-15 points on the Child-Pugh scale);
hemorrhagic diathesis and other blood clotting disorders;
severe dehydration (due to vomiting, diarrhea, or insufficient fluid intake);
III trimester of pregnancy and breastfeeding period;
Due to the ethanol content in the medicinal product, the medicinal product is contraindicated for neuraxial (intrathecal or epidural) administration.
Interaction with other medicinal products and other types of interactions
The simultaneous use of the following drugs with NSAIDs is not recommended:
other NSAIDs (including selective cyclooxygenase-2 inhibitors), including salicylates in high doses (≥ 3 g/day). The simultaneous use of several NSAIDs increases the risk of gastrointestinal ulcers and bleeding due to their mutual enhancement of action;
Anticoagulants: NSAIDs enhance the effect of anticoagulants, such as warfarin, due to the high degree of binding of dexketoprofen to blood plasma proteins, as well as due to inhibition of platelet function and damage to the gastric and duodenal mucosa. If concomitant use is necessary, it should be carried out under the supervision of a physician and with careful monitoring of relevant laboratory parameters;
Heparin: increased risk of bleeding (due to inhibition of platelet function and damage to the gastric and duodenal mucosa). If concomitant use is necessary, it should be carried out under the supervision of a physician and with careful monitoring of relevant laboratory parameters;
Corticosteroids: increased risk of developing ulcers in the digestive tract or gastrointestinal bleeding;
Lithium (reported for several NSAIDs): NSAIDs increase the level of lithium in the blood, which can lead to intoxication (reduced renal excretion of lithium). Therefore, when starting dexketoprofen, when adjusting the dose or discontinuing the drug, it is necessary to monitor the level of lithium in the blood;
methotrexate in high doses (at least 15 mg per week). Due to the decrease in renal clearance of methotrexate against the background of the use of NSAIDs, its negative effect on the blood system is generally increased;
hydantoin derivatives and sulfonamides: possible increased toxicity of these substances.
The simultaneous use of such agents with NSAIDs requires caution:
diuretics, angiotensin-converting enzyme (ACE) inhibitors, antibacterial aminoglycosides and angiotensin II receptor antagonists. Dexketoprofen reduces the effectiveness of diuretics and other antihypertensive agents. In some patients with impaired renal function (e.g., in cases of dehydration or in the elderly), the use of cyclooxygenase inhibitors concomitantly with ACE inhibitors, angiotensin II receptor antagonists or antibacterial aminoglycosides may worsen renal function, which is usually reversible. When using dexketoprofen together with any diuretic, it is necessary to ensure that the patient is not dehydrated, and at the beginning of treatment it is necessary to monitor renal function;
methotrexate in low doses (less than 15 mg per week): due to the decrease in renal clearance of methotrexate against the background of the use of NSAIDs, its negative effect on the blood system in general is increased. In the first weeks of simultaneous use, it is necessary to conduct a blood test every week. Even with a slight impairment of renal function, as well as in elderly patients, treatment should be carried out under strict medical supervision;
zidovudine: there is a risk of increased toxicity to erythrocytes due to effects on reticulocytes, which leads to severe anemia after the first week of NSAID use. A blood test and reticulocyte count should be performed within 1-2 weeks of starting NSAID use;
Sulfonylureas: NSAIDs can enhance the hypoglycemic effect of these agents by displacing sulfonylureas from their plasma protein binding.
Possible interactions should be considered when using the following agents:
beta-blockers: NSAIDs can weaken their antihypertensive effect by inhibiting prostaglandin synthesis;
Cyclosporine and tacrolimus: possible increase in nephrotoxicity due to the effect of NSAIDs on renal prostaglandins. Renal function should be monitored during combination therapy;
thrombolytic agents: increased risk of bleeding;
Antiplatelet agents and selective serotonin reuptake inhibitors: increased risk of gastrointestinal bleeding;
Probenecid: an increase in the concentration of dexketoprofen in the blood plasma is possible, which is probably due to inhibition of renal tubular secretion and conjugation of the drug with glucuronic acid and requires correction of the dose of dexketoprofen;
cardiac glycosides: NSAIDs can increase the concentration of glycosides in blood plasma;
Mifepristone: there is a theoretical risk that the efficacy of mifepristone may be altered by prostaglandin synthetase inhibitors. Limited data suggest that co-administration of NSAIDs on the same day as a prostaglandin does not adversely affect the efficacy of mifepristone or prostaglandin in cervical ripening or contractility, nor does it reduce the clinical efficacy of medical abortion.
quinolone antibiotics: results of animal studies have shown that the use of quinolone derivatives in high doses in combination with NSAIDs increases the risk of seizures;
Tenofovir: when used together with NSAIDs, the concentration of urea nitrogen and creatinine in the blood plasma may increase, therefore, to assess the possible effect of the combined use of these drugs, it is necessary to monitor renal function;
Deferasirox: Concomitant use with NSAIDs may increase the risk of gastrointestinal toxicity. Careful patient monitoring is required when this medicinal product is used concomitantly with deferasirox;
Pemetrexed: Concomitant use with NSAIDs may reduce the elimination of pemetrexed, therefore caution should be exercised when using high doses of NSAIDs. Patients with mild to moderate renal impairment (creatinine clearance 45 to 79 ml/min) should avoid NSAIDs for two days before and two days after taking pemetrexed.
Application features
Use with caution in patients with a history of allergic conditions. Avoid use of the drug in combination with other NSAIDs, including selective cyclooxygenase-2 inhibitors. Adverse reactions can be reduced by using the lowest effective dose for the shortest time necessary to improve the condition.
Gastrointestinal safety
Gastrointestinal bleeding, ulceration or perforation, in some cases fatal, have been reported with all NSAIDs at various stages of treatment, regardless of the presence of warning symptoms or a history of serious gastrointestinal disease. If gastrointestinal bleeding or ulceration occurs, the drug should be discontinued. The risk of gastrointestinal bleeding, ulceration or perforation increases with increasing NSAID dose, in patients with a history of ulcer, especially if complicated by bleeding or perforation, and in the elderly.
Elderly patients: Elderly patients have an increased frequency of adverse reactions to NSAIDs, especially gastrointestinal bleeding and perforation, sometimes fatal. Treatment of such patients should be started at the lowest possible dose. As with all NSAIDs, patients with a history of esophagitis, gastritis and/or peptic ulcer disease should be sure that these diseases are in remission. Patients with existing symptoms of gastrointestinal pathology and a history of gastrointestinal diseases should be monitored for possible disorders during the use of the drug, especially gastrointestinal bleeding. NSAIDs should be prescribed with caution to patients with a history of gastrointestinal diseases (ulcerative colitis, Crohn's disease), since there is a risk of their exacerbation. For such patients and patients taking low-dose acetylsalicylic acid or other agents that increase the risk of gastrointestinal adverse reactions, combination therapy with protective agents, such as misoprostol or proton pump inhibitors, should be considered.
Caution should be exercised when prescribing the drug to patients who are concomitantly taking agents that may increase the risk of ulceration or bleeding, such as oral corticosteroids, anticoagulants (e.g. warfarin), selective serotonin reuptake inhibitors or antiplatelet agents such as acetylsalicylic acid.
Kidney safety
Patients with impaired renal function should be prescribed the drug with caution, since against the background of the use of NSAIDs, deterioration of renal function, fluid retention in the body and edema are possible. Due to the increased risk of nephrotoxicity, the drug should be prescribed with caution in treatment with diuretics, as well as in those patients who may develop hypovolemia. During treatment, the body should receive a sufficient amount of fluid to avoid dehydration, which can lead to increased toxic effects on the kidneys. Like other NSAIDs, the drug may increase the concentration of urea nitrogen and creatinine in the blood plasma. Like other prostaglandin synthesis inhibitors, its use may be accompanied by adverse reactions from the kidneys, leading to glomerulonephritis, interstitial nephritis, papillary necrosis, nephrotic syndrome and acute renal failure. Most impaired renal function occurs in elderly patients.
Liver safety
Patients with impaired liver function should be prescribed the drug with caution. As with other NSAIDs, the drug may cause a temporary and slight increase in the values of some liver parameters, as well as a pronounced increase in the activity of AST and ALT. If these parameters increase, therapy should be discontinued.
Most liver dysfunction occurs in elderly patients.
Cardiovascular and cerebrovascular safety
Patients with arterial hypertension and/or mild to moderate heart failure require monitoring and advice. Particular caution should be exercised when treating patients with a history of heart disease, in particular with previous episodes of heart failure (the risk of heart failure increases with the use of the drug), since fluid retention in the tissues and the formation of edema have been observed during treatment with NSAIDs. Clinical studies and epidemiological data suggest that the risk of arterial thrombosis (for example, myocardial infarction or stroke) may be slightly increased with the use of some NSAIDs (especially in high doses and for long periods). There is insufficient data to exclude such a risk with the use of dexketoprofen. Therefore, in case of uncontrolled arterial hypertension, congestive heart failure, ischemic heart disease, peripheral arterial disease and/or cerebrovascular disease, dexketoprofen should be prescribed only after careful assessment of the patient's condition. Equally careful assessment should be performed before initiating long-term treatment in patients with risk factors for cardiovascular disease (such as hypertension, hyperlipidemia, diabetes mellitus, smoking).
Non-selective NSAIDs can reduce platelet aggregation and increase bleeding time by inhibiting prostaglandin synthesis. The simultaneous use of dexketoprofen trometamol and low molecular weight heparin in prophylactic doses in the postoperative period was studied in clinical studies and no effect on coagulation parameters was found. However, patients who use dexketoprofen trometamol simultaneously with drugs that affect hemostasis (e.g. warfarin, other coumarins or heparins) should be under close medical supervision. The greatest number of cardiovascular system dysfunctions occurs in elderly patients.
Skin reactions
Very rare cases of serious skin reactions (some fatal) have been reported with NSAIDs, including exfoliative dermatitis, Stevens-Johnson syndrome and toxic epidermal necrolysis. The risk of these reactions appears to be greatest at the start of treatment, with most patients experiencing them within the first month of treatment. The drug should be discontinued if skin rash, signs of mucosal involvement or other signs of hypersensitivity occur.
Masking the symptoms of underlying infections
The drug may mask the symptoms of infections, which may prevent diagnosis and timely treatment and, thereby, worsen the consequences of the infection. Such cases have been observed with bacterial pneumonia and bacterial complications of chickenpox. When the drug is administered for the relief of pain associated with an infectious process, monitoring of the infectious process is recommended. In outpatient settings, the patient should consult a doctor if symptoms persist or worsen.
Other information
Particular caution should be exercised when prescribing the drug to patients:
with hereditary disorders of porphyrin metabolism (for example, in acute intermittent porphyria);
with dehydration;
immediately after major surgical interventions.
In very rare cases, severe acute hypersensitivity reactions (e.g. anaphylactic shock) have been observed. At the first signs of severe hypersensitivity reactions after taking the drug, treatment should be discontinued. Depending on the symptoms, any necessary treatment in such cases should be carried out under the supervision of a doctor.
Patients with asthma in combination with chronic rhinitis, chronic sinusitis and/or nasal polyps are at higher risk of allergy to acetylsalicylic acid and/or NSAIDs than other patients. The administration of this drug may cause asthma attacks or bronchospasm, especially in patients with allergy to acetylsalicylic acid or NSAIDs.
Severe infectious complications of the skin and soft tissues may develop in the setting of chickenpox. To date, there is no data to rule out the role of NSAIDs in aggravating this infectious process. Therefore, the drug is not recommended for use in chickenpox.
The drug should be administered with caution to patients with hematopoietic disorders, systemic lupus erythematosus, and mixed connective tissue diseases.
As with other NSAIDs, dexketoprofen trometamol may mask the symptoms of infectious diseases during its use. In isolated cases, activation of infectious processes localized in soft tissues has been reported during the use of NSAIDs. Therefore, if symptoms of a bacterial infection appear or worsen during use, patients are advised to consult a doctor immediately.
This medicinal product contains 12.35 vol. % ethanol (alcohol), i.e. 200 mg/dose, equivalent to 5 ml of beer or 2.08 ml of wine per dose. Harmful for patients with alcoholism. Caution should be exercised when used in pregnant and breastfeeding women, children and patients with liver disease and epilepsy.
This medicinal product contains less than 1 mmol sodium (23 mg)/dose, i.e. essentially ‘sodium-free’.
Use during pregnancy or breastfeeding
The use of the drug is contraindicated in the third trimester of pregnancy and during breastfeeding.
Pregnancy
Inhibition of prostaglandin synthesis may adversely affect pregnancy and/or fetal development. Epidemiological studies have shown that the use of drugs that inhibit prostaglandin synthesis in early pregnancy increases the risk of miscarriage, fetal heart defects and anterior abdominal wall non-union. Thus, the absolute risk of developing cardiovascular anomalies increased from < 1% to approximately 1.5%. It is believed that the risk of such phenomena increases with increasing dose and duration of therapy. The use of prostaglandin synthesis inhibitors in animals caused an increase in pre- and post-implantation losses and increased embryo-fetal mortality. In addition, in animals treated with prostaglandin synthesis inhibitors during organogenesis, the incidence of fetal malformations, including cardiovascular anomalies, increased. However, studies of dexketoprofen trometamol in animals did not reveal reproductive toxicity. The use of dexketoprofen from the 20th week of pregnancy may cause oligohydramnios due to fetal renal dysfunction. This may occur shortly after the start of treatment and is usually reversible after discontinuation of the drug. In addition, cases of narrowing of the ductus arteriosus in the fetus have been reported after taking the drug in the second trimester of pregnancy, most of which resolved after discontinuation of treatment. Therefore, the appointment of dexketoprofen trometamol in the first and second trimesters of pregnancy is possible only in case of extreme necessity. When prescribing dexketoprofen trometamol to women planning a pregnancy or in the first and second trimesters of pregnancy, the lowest possible effective dose should be used for the shortest possible duration of treatment. Antenatal monitoring for oligohydramnios and narrowing of the ductus arteriosus in the fetus should be considered in case of exposure to dexketoprofen for several days, starting from the 20th week of gestation. Pregnant women should discontinue dexketoprofen if oligohydramnios or narrowing of the ductus arteriosus in the fetus is detected.
During the third trimester, all prostaglandin synthesis inhibitors cause:
Risks to the fetus:
cardiopulmonary toxic syndrome (narrowing/occlusion of the ductus arteriosus and pulmonary hypertension);
renal impairment (see above).
Risks for mother and baby at the end of pregnancy:
prolongation of bleeding time (effect of inhibiting platelet aggregation), which is possible even when using low doses;
Delayed uterine contractions with corresponding delayed labor and prolonged labor.
Breast-feeding
There is no data on the penetration of dexketoprofen into breast milk. The drug is contraindicated during breastfeeding.
Fertility
As with all NSAIDs, dexketoprofen trometamol may impair female fertility and is therefore not recommended in women attempting to conceive. Women who have difficulty conceiving or are undergoing investigation of infertility should consider discontinuing the drug.
Ability to influence reaction speed when driving vehicles or other mechanisms
While using the drug, dizziness, visual disturbances or drowsiness may occur. In such cases, the ability to react quickly, navigate the road situation and drive vehicles or other mechanisms may deteriorate.
Method of administration and doses
To minimize adverse reactions, the lowest effective dose should be used for the shortest period of time (see section "Special warnings and precautions for use").
Adults. The recommended dose is 50 mg every 8-12 hours. If necessary, a second dose should be administered after 6 hours. The maximum daily dose should not exceed 150 mg. The drug is intended for short-term use, therefore it should be used only during acute pain (no longer than 2 days). Patients should be transferred to oral analgesics, if possible. For moderate to severe postoperative pain, the drug can be used according to indications in the same recommended doses in combination with opioid analgesics.
Elderly patients: Dose adjustment is usually not required. However, due to physiological decline in renal function, a lower dose is recommended, with a maximum daily dose of 50 mg in mild renal impairment.
Hepatic impairment. For patients with mild to moderate liver disease (Child-Pugh score 5-9), the maximum daily dose should be reduced to 50 mg and liver function should be closely monitored. In severe liver disease (Child-Pugh score 10-15), the drug is contraindicated.
Renal impairment: For patients with mild renal impairment (creatinine clearance 60-89 ml/min), the maximum daily dose should be reduced to 50 mg. In patients with moderate or severe renal impairment (creatinine clearance < 59 ml/min), the drug is contraindicated.
Children and adolescents: The medicine should not be used in children and adolescents due to a lack of data on its efficacy and safety.
Method of application
Intramuscular injection.
The contents of one ampoule (2 ml) should be slowly injected deep into the muscle.
Intravenous infusion.
For intravenous infusion, the contents of the 2 ml ampoule should be diluted in 30-100 ml of 0.9% sodium chloride solution, glucose solution or Ringer-lactate solution. The infusion solution should be prepared under aseptic conditions, avoiding exposure to natural daylight. The prepared solution should be clear. The infusion should be carried out intravenously slowly over 10-30 minutes.
The drug, diluted in 100 ml of 0.9% sodium chloride solution or in glucose solution, can be mixed with dopamine, heparin, hydroxyzine, lidocaine, morphine, pethidine and theophylline.
Intravenous injection (bolus administration).
If necessary, the contents of one ampoule (2 ml of solution for injection) should be administered intravenously slowly over at least 15 seconds. The drug can be mixed in small volumes (e.g. in a syringe) with injectable solutions of heparin, lidocaine, morphine and theophylline.
The drug should not be mixed in small volumes (e.g. in a syringe) with solutions of dopamine, promethazine, pentazocine, pethidine and hydroxyzine, as a precipitate forms.
Diluted infusion solutions should not be mixed with promethazine or pentazocine.
The drug can only be mixed with the medicines listed above.
For intramuscular or intravenous bolus administration, the drug should be administered immediately after it has been withdrawn from the ampoule.
When storing diluted drug solutions in polyethylene bags or in products made of ethyl vinyl acetate, cellulose propionate, low-density polyethylene, and polyvinyl chloride designed for administration, no changes in the content of the active substance due to sorption were observed.
The drug is intended for single use, therefore the remains of the prepared solution should be disposed of. Before administration, it is necessary to visually check that the solution is clear and colorless. The solution containing solid particles should not be used.
Children.
The medicine should not be used in children and adolescents due to a lack of data on its efficacy and safety.
Overdose
Symptoms of overdose are unknown. Similar drugs cause disorders of the digestive tract (vomiting, anorexia, abdominal pain) and the nervous system (drowsiness, dizziness, disorientation, headache). In case of accidental overdose, symptomatic treatment should be immediately initiated according to the patient's condition. Dexketoprofen trometamol is removed from the body by dialysis.
Side effects
The table below lists, by organ system and frequency, adverse reactions considered at least possibly related to dexketoprofen trometamol in clinical trials, as well as adverse reactions reported after the drug was marketed.
Organs and organ systems
Often
(≥1/100 –
<1/10)
Sometimes
(≥1/1000 –
<1/100)
Rarely
(≥1/10000 –
<1/1000)
Very rare
(<1/10000)
Blood/lymphatic system disorders
_
Anemia
_
Neutropenia, thrombocytopenia
Immune system disorders
_
_
Swelling of the larynx
Anaphylactic reactions, including anaphylactic shock
Injection site pain, injection site reactions including inflammation, hematoma, bleeding
Fever, fatigue, pain, chills, asthenia, malaise
Trembling,
peripheral edema
Specifications
Characteristics
Active ingredient
Dexketoprofen
Adults
Can
ATC code
M MEDICINES AFFECTING THE MUSCULOSKOLE SYSTEM; M01 ANTI-INFLAMMATORY AND ANTIRHEUMATIC MEDICINES; M01A NON-STEROIDAL ANTI-INFLAMMATORY AND ANTIRHEUMATIC MEDICINES; M01A E Propionic acid derivatives; M01A E17 Dexketoprofen
Country of manufacture
Ukraine
Diabetics
Can
Dosage
25 mg/ml
Drivers
With caution
For allergies
With caution
For children
It is impossible.
Form
Ampoules
Method of application
Injections
Nursing
It is impossible.
Pregnant
It is impossible.
Primary packaging
ampoule
Producer
Health FC LLC
Quantity per package
10 ampoules
Trade name
Ketodex
Vacation conditions
By prescription
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