Letter to the Editor Response

T hank you for the opportunity to respond to the points put forth by the reader regarding the use of SPRIX ® (ketorolac tromethamine) nasal spray. As the developer of SPRIX ® , the reader points out that prior pharmacokinetic data comparing oral with intramuscular (IM) ketorolac indicate that the time for the drug to reach maximum plasma concentration (t max) is as low as 20 minutes in fasted individuals 2 but may be slowed to 91 minutes in subjects after a high-fat breakfast. 4 The reader also asserts that taking oral ketorolac on a full stomach is " a situation likely to occur in real-life settings " and, thus, a strong reason to favor the intranasal over the oral route of the drug. We agree that this certainly is a logical assertion. However, it must be kept in mind that the patient population of interest, specifically, professional football players in the National Football League (NFL), may not necessarily have had a high-fat content meal at the time of ketorolac use, as was studied by Mroszczak et al. 4 Given the fact that these players are taking the medication either just prior to or during a game when a high-fat content meal would more likely hinder rather than help performance, it is more likely that the players' stomachs would be nearly empty or, at most, contain merely clear liquids. There is no study, to our knowledge, that has evaluated the absorption kinetics of oral ketorolac taken in conjunction with clear liquids, such as sports drinks, commonly used prior to and during athletic competition. The reader also points out that oral ketorolac (10 mg) is not indicated by the Food and Drug Administration (FDA) for first-line analgesic therapy since it was originally approved for use as continuation therapy following intravenous (IV) or IM dosing of ketorolac tromethamine. As mentioned in our article, we acknowledge that the use of oral ketorolac without prior IV or IM dosing is considered " off-label. " In our experience, the isolated use of oral ketorolac is quite common outside of the NFL for its analgesic properties following acute strains and sprains and overuse injuries and as an adjunct to narcotic medication. In addition, there have been no complications that we are aware of related to the isolated use of oral ketorolac within the appropriate dosing schedule of 10 mg every 4 to 6 hours, with a …