Analgesic
Ketorolac
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Ketorolac
, Toradol, SPRIX
See Also
Nonsteroidal Anti-inflammatory
Indications
See
NSAID
Analgesia for moderate to severe acute pain
Alternative to
Narcotic Analgesic
Contraindications
See
NSAID
Peptic Ulcer Disease
Renal Insufficiency
Acute or chronic bleeding risk
Hypersensitivity
to
Aspirin
or other
NSAID
Age <2 years old
Mechanism
See
NSAID
NSAID
in the Acetic acid class (Pyrrolo-pyrrole)
Non-selective
NSAID
that inhibits both COX-1 and COX-2, reducing
Prostaglandin
synthesis
Antiinflammatory activity is via COX-2 enzyme inhibition
Precautions
See
NSAID
s
Do not use longer than 5 days
Do not repeat two Ketorolac courses back to back
Dosing
Child
Not FDA approved for use in children (dosing below is off-label)
Dose 0.5 mg/kg/dose (up to 30 mg/dose) IM or IV every 6 hours as needed
Dosing Adult General
Avoid oral Ketorolac (other
NSAID
s are at least as effective orally, with fewer adverse effects)
Ketorolac is typically as effective at lower dose than the originally approved doses (with fewer adverse effects)
Use 30 mg IM (instead of 60 mg IM)
Use 10 to 15 mg IV (instead of 30 mg IV)
Ketorolac may have ceiling effect at 10 mg (at which higher doses offer no effect)
Motov (2017) Ann Emerg Med 70(2):177-84 +PMID:27993418 [PubMed]
Limit maximum daily dose to 60 mg/day (in divided doses)
Age over 65 years
Renal
Impairment
Weight under 50 kg (110 pounds)
Dosing
Adult Intramuscular dose
Low dose (preferred, typical use)
Single dose: 30 mg IM
Repeated dose: 15 mg IM every 6 hours prn (<5 days)
Maximum: 60 mg per day
Regular dose (originally approved dosing)
Single dose: 60 mg IM
Repeated dose: 30 mg IM every 6 hours prn (<5 days)
Maximum: 120 mg per day
Dosing
Adult Intravenous Dose
Lower dose (preferred, typical use)
Ketorolac 15 mg IV every 6 hours as needed <(5 days) OR
Ketorolac 10 mg IV every 6 hours as needed
Dose 10 mg appears to be as effective as the 15 and 30 mg doses
Analgesic
ceiling dose may be 10 mg, above which are more adverse effects without benefit
Motov (2017) Ann Emerg Med 70(2):177-84 +PMID:27993418 [PubMed]
Regular dose (originally approved dosing, and may have no benefit over 10-15 mg dose)
Ketorolac 30 mg IV every 6 hours prn (<5 days)
Dosing
Adult Oral dose (continuation of
Parenteral
dosing)
Consider other
NSAID
s which are typically as effective, with less
Gastrointestinal Bleeding
risk
Maximum: 40 mg per day
Low dose (preferred, if oral Ketorolac is used at all)
Dose: 10 mg PO every 4 to 6 hours prn
Regular dose
First dose: 20 mg PO (two 10 mg tablets)
Subsequent dosing: 10 mg PO q4-6 hours prn
Dosing
Adult Intranasal
Preparation: Ketorolac
Tromethamine
One spray delivers 15.75 mg of Ketorolac
Tromethamine
Use every 6-8 hours (maximum 4 times daily)
Typical Dose: One spray each notsril
Reduced Dose: One spray in one nostril
Indicated in over age 65 years, weight <110 lbs or renal
Impairment
Local adverse effects
See adverse effects below and
NSAID
s for systemic effects
Nasal discomfort
Increased
Lacrimation
Throat irritation
References
Fitzgerald (2020) Crit Dec Emerg Med 34(10): 24
Adverse Effects
See
NSAID
Gastrointestinal Bleeding
(
Peptic Ulcer Disease
)
See
NSAID Gastrointestinal Adverse Effects
Among the highest
Gastrointestinal Bleeding
risks of any
NSAID
Exacerbation of
Renal Insufficiency
See
NSAID Renal Adverse Effects
Bleeding risk
Higher risk of bleeding complications than with other
NSAID
s (likely related to anti-
Platelet
activity)
Avoid in postoperative patients with risk of bleeding complications (e.g.
Tonsillectomy
)
Safety
See
NSAID
Considered safe in
Lactation
Avoid
NSAID
s in pregnancy outside the first part of the second trimester (13 to 20 weeks)
Teratogen
ic in first trimester
Risk of premature ductus arteriosus closure in the fetus in third trimester
Most
NSAID
s carry a legacy system Pregnancy Category B or C designation (aside from third trimester)
However, many obstetricians avoid
NSAID
s entirely in pregnancy (even in second trimester)
Efficacy
Most
NSAID
s have equivalent efficacy to
Parenteral
Ketorolac (and to some
Opioid
s)
Equivalents to Toradol 60 mg IM
Morphine
12 mg IM
Most
NSAID
S (and similar onset of action to
IM Injection
)
Ibuprofen
800 mg orally
Naprosyn
500 mg orally
Advantages over
Morphine
in ER with blunt limb
Trauma
Toradol has longer duration
Toradol less adverse effects
Toradol IV more effective than
Morphine
IV
References
Rainer (2000) BMJ 321:1247-51 [PubMed]
Resources
Ketorolac Oral Tablets (DailyMed)
https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=688f5dec-a6db-43c6-a1f8-5df99d08d395
Ketorolac Injectable Solution (DailyMed)
https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=8accbb78-fc64-45d5-69b0-35c23a1d2a2e
References
(2012) Presc Lett 19(6): 33
Turturro (1995) Ann Emerg Med 26:117-20 [PubMed]
(2000) Med Lett Drugs Ther 42(1085): 73-78 [PubMed]
Vadivelu (2015) Pain Pract 5(2):175-93 +PMID: 24738596 [PubMed]
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