(1203) Scheduled IV Ketorolac after Cesarean Delivery and Effects on Opioid Use: A cost effectiveness analysis

Inadequate pain control after cesarean section has been associated with a greater risk of opioid use and postpartum depression. With cesareans being among the most common surgeries performed, it is imperative to use a pain control strategy that reduces opioid use while achieving adequate pain control. The use of opioid-sparing multimodal analgesia has been increasing over the past decade, with opioids being primarily utilized for breakthrough pain. The American College of Obstetricians and Gynecologists (ACOG) recommends scheduled NSAIDs as first-line postoperative analgesia. However, the optimal type, dose, and timing of administration have not yet been defined. In this study, we evaluated the cost-effectiveness of scheduled IV ketorolac versus placebo in reducing the risk of developing an opioid use disorder (OUD), overdose, and opioid-related death.

Study Design:

We constructed a decision-analytic model to compare outcomes between receiving IV ketorolac and IV normal saline. Our theoretical cohort included 1,161,896 individuals, reflecting the number of cesareans performed in 2023. Outcomes were the development of an OUD, overdose, opioid-related death, costs, and quality adjusted life years (QALYs). We used a willingness-to-pay threshold of $100,000/QALY. Model inputs were derived from the literature and assessed through sensitivity analyses. 

Results:

In our cohort, the use of IV ketorolac was associated with 6,739 fewer cases of OUD, 439 fewer cases of having an opioid-related overdose, and 11 fewer cases of opioid-related death. Prescribing IV ketorolac was cost-effective with an ICER of $531.93/QALY. Once variability was incorporated into our model inputs via a Monte Carlo simulation, we found that IV ketorolac was cost-effective and cost-saving in 86% of the samples.

Conclusion:

In our study, prescribing IV ketorolac was a cost-effective strategy to improve outcomes and minimize the adverse events associated with opioid prescription. Adopting a standard of prescribing IV ketorolac post-cesarean delivery would be advantageous for both recovery of patients and the health system.