TORADOL (ketorolac) linked to Recurrence Prevention

Options
1679111221

Comments

  • solfeo
    solfeo Member Posts: 838
    edited June 2018

    Hi Sassy - We weren't talking about the Toradol for the entire time, but we did spend a good amount of time on it. Her objections were the usual ones - risk of bleeding and hematoma. When she did finally say she would be willing to do it, she said (I paraphrase) "As long as you understand it can cause bleeding and hematoma, which can lead to a seroma and other complications." She did mention that a lot of other surgeons won't use it at all, but that she did have some experience operating on people who had been given Toradol in the ER and then had to be rushed into the OR, so she had no choice, and it usually worked out OK. But that she had also seen the bleeding problems at times. I guess not in planned breast surgery because she hasn't been using it.

    She said she was already aware of the studies, but that they were small studies that were not reliable because of the way they were done. I wish I could remember exactly what she said here, but it was something about an unusual number of recurrences in the non-Toradol group ("There was something else going on in the original study"), and that the other studies have only been in a laboratory or with animals.

    I did use your Dear Doctor, lightly edited, in my original email to her. I left out the "You do not have permission to refuse my request" part, because I personally think that kind of direct statement can cause the recipient of the information to resist. It could be received as confrontational and cause them to put up walls before the conversation even starts. Eventually I did have to actually firmly refuse to take any opiates whether she agreed to the Toradol or not. She thought it shouldn't be an issue for the SNB, or maybe even the mastectomy alone, but for the MX with TE (I'm still not decided) she said she would be very surprised if anyone could do it without the narcotics due to the level of pain. I told her women here are already doing it, but I couldn't remember exact circumstances so I couldn't tell her with certainty that no one is having issues with regard to MX with TE. I guess that is probably an individual thing.

    I do wonder if suffering through unrelieved severe pain just to avoid opiates may create its own issues with inflammation and suppression of the immune system, which is why I have said (not to her but elsewhere on these boards) that I probably would be willing to take something stronger if the pain was that bad. In that case, I would try to take as little as possible and continue to address the inflammation in other ways. I think the original surgeon's idea of alternating the Toradol with the Tylenol 3 if necessary, would be a good way to do that. I already have the Tylenol w/codeine prescription if I need it.

  • Hopeful82014
    Hopeful82014 Member Posts: 3,480
    edited September 2015
    FWIW - One surgeon I spoke to also belittled the studies and expressed huge concern over bleeding. (Really? I'd rather bleed than recur.) She then triumphantly said 'and besides that, there's a nationwide shortage due to a recall and we don't have any.'

    That was just one of several reasons I cancelled that surgery and found another - and MUCH better - surgeon who was willing to consider, and then order, the use of Toradol.
  • Stephmoen
    Stephmoen Member Posts: 563
    edited September 2015

    I am so surprised that some have had such a difficult time getting this approved I asked about it had prepared a speech and had articles printed out and my surgeon and plastic surgeon both simply said ok...my surgeon said she hasn't heard of using it before surgery but said she would do it and told me I am so cute because of all my research..I am 30 and have 2 young kids I want to do everything possible to keep this cancer from coming back. Both my plastic surgeon and surgeon said the only concern was bleeding but felt that it wouldn't be an issue.

  • sas-schatzi
    sas-schatzi Member Posts: 19,603
    edited September 2015

    Hopeful, that doc was gradeFK Asshole, who probably hasn't opened a book in years and graduated bottom in his class...............hmm what else awful can I say about him. Thank God, you found a reasonable doc. Did you have any bleeding problems? Was it pre-incision? How many doses? What did you think of the pain relief? What did the surgeon say after? What did the anesthesia person say? Did they know of the studies? What was the surgeons comments about the study? Details, details,details? What do you think now? How do you feel about working the problem? Everything about your point of view? Yes, I'm asking for a dissertation LOL.

    Stephy, I'll try and look at Forget's. The injection is given in the OR pre-incision, but I'll verify. When is your sx? Some where I got it drilled into my brain pre-incision. Read Solfeo's & Hopeful's experience with the doc or maybe it was Rainny. All the questions I asked Hopeful, when all is said and done, please, the same for you.

  • sas-schatzi
    sas-schatzi Member Posts: 19,603
    edited September 2015

    Rainey nix on spinal anesthesia. I bypassed that. What Falleaves was advocating for was a paravertebral block. Way different than spinal. ANYTHING that even has the hint of causing bleeding should NEVER be used if the spinal area is entered. Posting this now and continuing to read your posts

  • Hopeful82014
    Hopeful82014 Member Posts: 3,480
    edited September 2015
    "Hopeful, that doc was gradeFK Asshole, who probably hasn't opened a book in years and graduated bottom in his class...............hmm what else awful can I say about him. Thank God, you found a reasonable doc. Did you have any bleeding problems? Was it pre-incision? How many doses? What did you think of the pain relief? What did the surgeon say after? What did the anesthesia person say? Did they know of the studies? What was the surgeons comments about the study? Details, details,details? What do you think now? How do you feel about working the problem? Everything about your point of view? Yes, I'm asking for a dissertation LOL."


    Sassy - sadly, that surgeon was a woman - and a real btch; not a word I use lightly. She is very high up in the breast care health program at the hospital where my imaging was done, which is really sad. What's just as bad is that the MO (another woman) she recommended is another real witch. I had provided the surgeon with copies of the studies - she was incredibly dismissive.

    The anesthetist had no problems using Toradol although she was careful to check that it wouldn't be contraindicated by other drug interactions. I'd have to read through the surgical report to be sure that it was pre-incision but from what my surgeon said I believe it was. Ditto on the number of doses.

    I'm going to have a follow up conversation eventually with my surgeon's NP and with the anesthesiologist to make sure they have copies of the studies, understand the potential and can incorporate it into their surgical planning rather than women needing to stumble on it themselves.

    I had no bleeding issues and the pain relief was fine. The oral Toradol that I used post-surgery did a great job.

  • sas-schatzi
    sas-schatzi Member Posts: 19,603
    edited September 2015

    He's coming.........................................

  • MichaelRetsky
    MichaelRetsky Member Posts: 5
    edited September 2015

    Hello friends,

    What can I do to help?

    Michael Retsky

  • sas-schatzi
    sas-schatzi Member Posts: 19,603
    edited September 2015

    Dr. Retsky, WOW what fun you are here. Let me get over the breathlessness LOL. The biggest thing I would like to know is are we going in the right direction. They're members that post here, and they're members that lurk. I won't explain lurkers as I know you are familiar with on-line forums. We know that other members that have upcoming surgery, are being told by others that have read here, that they may want to check out the Toradol thread.

    This thread well be here as long as BCO. Our words have to be right. Lives and quality of life is at stake. :)

    When I meet aresearcher or inventor, I always like to know what sparked their interest in a particular thing. How did you see the connection between Toradol, inflammation, and recurrence?. Was it before or after Forget's work?

    More to come, but that's a start

  • sas-schatzi
    sas-schatzi Member Posts: 19,603
    edited September 2015

    Dr Retsky will you be reading from the beginning? Generally, on a thread like this a member seeking information before surgery will read from the beginning to pick up on the whole discussion. If you find anything that is not true, could you make a note and we will fix it. We have the ability to edit our posts.

    Could you give and overview of where you believe the research is going?

    Have you lectured to or have you had any feed back from ASCO? American College of Surgeons? Anesthehsia folks?

    Do you see a movement to use the drug without the definitive prospective study not being done yet?

    A few pages back I put together a DEAR DOCTOR letter that has your's and Forget's studies. Plus, some studies on bleeding. I should make the lead statement less confrontational. But It was before coffee, and someone had trouble with their doc. For those that have posted, it's a mixed bag as to response from their MO/anesthesia/PS/ BS. From never heard of the studies, to much risk of bleeding, to simple "NO, we don't do that." Suggesstion?

    More questions coming. Variability as to who shows up and when. No two days are alike

  • sas-schatzi
    sas-schatzi Member Posts: 19,603
    edited September 2015

    Dr. Retsky, I sent a PM to all that have posted here. Tea or coffee?

    Friends post your questions. I'm sure that Dr.Retsky will be around for awhile. I hope. The ability to question an expert in a field so close to our hearts, is beyond exciting. I originally put "close to our boobs", but he doesn't know our humor yet.

  • sas-schatzi
    sas-schatzi Member Posts: 19,603
    edited September 2015

    Dr Retsky, Is pre-incision the most opportune time to give Toradol? My reading said pre-incision, but second guessed myself when someone recently asked the direct question. My intent was to go back and find it. Well....you are here :)

  • MichaelRetsky
    MichaelRetsky Member Posts: 5
    edited September 2015

    I gave a talk to the Angiogenesis Foundation in 2012 that is on their website. Here is link: https://www.angio.org/ I am in the "hear from the experts" between the two females.


    I was just in Nigeria in July and gave three talks to clinical and surgical staffs. They liked the idea and we jointly submitted a grant proposal

    to do a clinical trial. Amt requested is $2.6 million. They have high incidence of triple negative and don't use mammography so patients have

    poor prognosis. That's bad for them but good if we want to demonstrate reduced early relapses.

    I understand you and your fellow members are concerned about bleeding. I hear that often. However Patrice Forget tells me

    that it does not happen in Brussels. They have been using ketorolac for years. By the way, Patrice is a young guy with a nice

    family. His name is pronounced in French as Forzhay. I have told many friends and others who have contacted me that I would

    use ketorolac if I or my wife needed surgery for cancer.

    I would probably make sure your anesthesiologist is doing it just as Forget uses it. I would put them in touch just to make sure

    there is no communication problem.

    Michael

  • peacestrength
    peacestrength Member Posts: 690
    edited September 2015

    Dr. Retsky, thank you for coming here and sharing information.

    I've already had a bi-lateral mx in 2013and received Toradol after surgery...wish I would have known about the research for using it pre-incision. My question is: I'm considering breast reconstruction, would you recommend Toradol pre-incision? And post reconstruction?


    Thank you.

  • MichaelRetsky
    MichaelRetsky Member Posts: 5
    edited September 2015

    I do understand humor among cancer patients in patient forums. I am a 20 year survivor of stage IIIc colon cancer. I am a founder and

    on board of directors of the Colon Cancer Alliance (www.ccalliance.org). I was on forums for a long time.

  • solfeo
    solfeo Member Posts: 838
    edited June 2018

    Hi Dr. Retsky and thank you for making yourself available to us.

    I think what many of us want to know is what to ask/tell our doctors, who in some cases don't want to make the time to learn more about something they already don't believe in. I don't see my sugeon making a phone call to Brussels.

    My surgeon agreed to do it under duress, but I don't know exactly what she'll be doing because I didn't know how much to ask for specifically. She suggested 30mg pre-op, and then I guess whatever is usually used for pain post-op. I didn't ask her to be more specific because I wouldn't know if her recommendations are good enough or not.

    Comment more than a question: I sure hope I don't have complications because it will probably put this surgeon off of ever trying for anyone else. There are risks to every surgery, and Toradol wouldn't necessarily be the cause, but that's how it's going to look to her.

  • sas-schatzi
    sas-schatzi Member Posts: 19,603
    edited September 2015

    Rainey, Opiates has been discussed very little here, Falleaves is into that research. I have not read everything she brought. I apologize for that.

    But with the current, past research, and working in the operating room for 12 years, these are my comments. A certain amount of opiods have to be used during surgery b/c otherwise the depth of anesthesia needed for cutting can't be achieved. The patient will feel it. The body does not like being cut. If adequate pain control is not used, the bodies "fright or flight" mechanisms kick in. The whole body will react. The technical---it activates the Sympathetic portion of the Autonomic Nervous System. To keep the body happy during surgery we make sure that we don't alert that system.

    What the studies related to pain show is that when Toradol is used, not as much opiod has to be used. They hit different receptor sites. The total pain control is improved for this reason. If you refer to one of my earliest post about anesthesia can be compared to a smorgasboard i.e. a little of this and a little of that. anesthesia can be achieved with a lesser amount of each drug. But each drug is an important part of the buffet. An amnesic--Versed, opiod-- sufentanil, aparalyzer--ketamine, a centrally acting vasoactive blood pressure med--like clonidine, and as in the case of this discussion Toradol. This is a balanced meal from the buffett of drugs available.---this is a balanced plan.

    Please, a balance between opiods and Toradol should be the goal. Sorry, I missed that in your post.

    Rainey, I will get to Falleaves studies and figure out what she meant.

  • MichaelRetsky
    MichaelRetsky Member Posts: 5
    edited September 2015

    The amount recommended by Patrice Forget is 20 mg preincisional in patients under

    60 kg, and 30 mg in patients over 60 kg. He is quite available by email. Phone call

    is not best way to contact him.

  • solfeo
    solfeo Member Posts: 838
    edited June 2018

    sas-schatzi wrote:

    "Please, a balance between opiods and Toradol should be the goal. Sorry, I missed that in your post"

    That's a good example of something I was totally confused about, and I did tell the surgeon I was refusing all opiates before/during/after surgery. I wrote earlier that I would probably give in to a little something post-op if the pain is too bad, alternating with the Toradol, but I didn't know we should be allowing opioids in surgery AT ALL.

    So now I'm afraid I have requested something that could make my situation worse, out of misunderstanding what we are supposed to be asking for.

  • sas-schatzi
    sas-schatzi Member Posts: 19,603
    edited September 2015

    Solfeo, Hmmmm Read my last post. AND You just tell your anesthesia doc that his/her standard use of opiates is okay. I have never said anywhere that opiates shouldn't be used.

    A usual operating room standard is, Versed given in pre-op, Then in the OR suite. an anesthesia person administers. Drugs in sequence in a fairly short time. An opiod, a drug to block the cardiovascular system sympathetic response--i.e clonidine, a paralyser--usualy ketamine. Toradol when used acts on a different set of pain receptors than opiod receptors.

    Post op pain control is best managed by a combination of Toradol(if used) and an opiod.

    I promise I will go and look at Falls studies. Plus, if you believe I have said not to use an opiod, point it out. So, I can figure out what's up.

  • rainnyc
    rainnyc Member Posts: 1,289
    edited September 2015

    Thanks, what you have said about the balance is so helpful. I sent the Retzky and Forget studies to the surgeon but received only the response that I can talk to the anesthesiologist the day of surgery (tomorrow). I doubt very much that the surgeon passed the studies along, so I will be starting from scratch. I have a lot to do to get ready, but I'm at least going to skim them again tonight so they are fresh in my mind for tomorrow.

    Will report back at some point, hoping that it might help others.

  • sas-schatzi
    sas-schatzi Member Posts: 19,603
    edited September 2015

    Solfeo, tell me where you got confused-----I don't want to assume anything

  • solfeo
    solfeo Member Posts: 838
    edited June 2018

    Sassy - See how misunderstandings occur in online communications, because I didn't mean my misunderstanding originated from you. I obviously did read your last post because I quoted it. My confusion is the culmination of conflicting information I've run across throughout researching the issue: hearing what other women are asking for; a personal difficulty with processing scientific jargon, etc. Just not knowing specifically what to ask for. Thus my original question.

    I have read this whole thread, and other related individual posts, but it's a lot of information to process and some of it conflicts. Just as another example, some have said they are asking for thoracic epidurals. But I think you said that's a bad idea if I understood your last post that addressed the issue (a few days ago I think). Conflicting info. Not making any judgments just never clear what/how to choose.

    Hope this clears things up about my struggle. Has nothing to do with anyone else. I'm just seeking clarification and guidance.

  • sas-schatzi
    sas-schatzi Member Posts: 19,603
    edited September 2015

    Solfeo, I get you, Bummed. Okay, you know the way I work. I find the source, then to the best of my ability find and answer that is understandable. i.e asking Dr Retsky to come help.

    Thoracic epidurals------must be in Falls literature. It's not something I've studied. But until I did, I would stick with what I stated earlier. Don't use Toradol with epidurals. Maybe that's a wrong answer, but not treading where I don't have a clue. Bleeding into an epidural space can be trouble.

    So, define for me what you are confused about by number and we will work it out.

  • Fallleaves
    Fallleaves Member Posts: 806
    edited September 2015

    Hi everybody, just wanted to weigh in a bit on the opioids. I've been away awhile, and it looks like I've missed a lot! Amazing to see Dr. Retsky posting here! (Thanks for the heads up, Sassy). I hope bringing up the negative effects of opioids doesn't freak anyone out. I have read mixed things about opioids. On the one hand pain itself is very immunosuppressive. So anything that aids in pain management, including opioids, is helpful. But opioids can, in higher doses, be immunosuppressive themselves, and there are some papers I've read that indicate opioid exposure promotes tumor growth in SOME animal models. So if you can use alternatives to opioids, that would be the best thing.

    The other drug I would avoid, if possible, is ketamine, which is VERY immunosuppressive (unless given with a beta-adrenergic antagonist).

    On the other hand paravertebral nerve blocks, propofol, and tramadol all have very beneficial effects for cancer patients.

    But, I am NOT an expert by any means. I just think if there are choices to be made, we should take the opportunity to ask for what might benefit us the most. We're not talking about experimental drugs, just choosing among drugs that have all been in use a long time.


  • sas-schatzi
    sas-schatzi Member Posts: 19,603
    edited September 2015

    Falleaves, YAY your back. I knew you had a handle on what you studied. Whew, you were here to save the DAY. Okay Ketamine and clonidine(beta adrenergic antagonist). Propofol(diprivan) and paravertebral blocks. Did you have anything in your materials about thoracic epidurals?

  • sas-schatzi
    sas-schatzi Member Posts: 19,603
    edited September 2015

    Falls, Just so happy you are back, felt like I was on a ledge. I knew I hadn't said anything, didn't want to sound Like I was dumping on you. Retsky was here. Kilroy left before he got here. I'm hoping he takes a look at the rest and tells us if we were off track anywhere. Solfeo was rightly upset and we are still working out her concerns, trying to figure if it's something from here. So stick close okay

  • solfeo
    solfeo Member Posts: 838
    edited June 2018

    Things are getting clearer already just from what has been said. My original instinct was that shunning opioids completely might not be such a good idea because you could be causing a different set of problems, as was said. But then I didn't want to take any chances when others were turning them down. Also the first surgeon was strongly discouraging opiate use, although not completely forbidding it. I had a gene test done on my cancer (not Oncotype but from a European lab) and it was determined that I am at high risk of recurrence/metastasis. I don't want to do one single thing to contribute to that happening.

    I don't remember running across a specific reason for the epidural vs paravertebral block, just reading what others have chosen. I want to do everything I can to minimize the need for opiates without causing other problems.

    I think I have a better idea what to do. Good thing my surgery today was postponed so I have a chance to talk to the surgeon again.

  • sas-schatzi
    sas-schatzi Member Posts: 19,603
    edited September 2015

    Falls, Okay, I think it's melding. Let's watch for solfeo's questions/concerns. Rainy has Retsky's response on dose. Which his dosing schedule is in both Forget's study and is referenced in Retsky's. The dosing schedule by Forget is very specific. It is different than the product labeling. Then going to call it a brain day.

    Need to find out how Forget came to figure out the dosing.

    Please, watch for Solfeo.

  • solfeo
    solfeo Member Posts: 838
    edited September 2015

    Well let me just clarify that I am not upset and you need to get off that ledge. ;-)

    No one expects you to know everything, or to be giving medical advice on the internet. I just wanted to have the conversation. For myself, but also because there must be lurkers who are having a hard time making these decisions too.

    Your hard work is much appreciated.

Categories