Ketorolac

Aka: Ketorolac, Toradol, SPRIX

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II. Indications

  1. See NSAID
  2. Analgesia for moderate to severe acute pain
  3. Alternative to Narcotic Analgesic

III. Contraindications

  1. See NSAID
  2. Peptic Ulcer Disease
  3. Renal Insufficiency
  4. Acute or chronic bleeding risk
  5. Hypersensitivity to Aspirin or other NSAID
  6. Age <2 years old

IV. Mechanism

  1. See NSAID
  2. NSAID in the Acetic acid class (Pyrrolo-pyrrole)
  3. Non-selective NSAID that inhibits both COX-1 and COX-2, reducing Prostaglandin synthesis
    1. Antiinflammatory activity is via COX-2 enzyme inhibition

V. Precautions

  1. See NSAIDs
  2. Do not use longer than 5 days
  3. Do not repeat two Ketorolac courses back to back

VI. Dosing: Child

  1. Not FDA approved for use in children (dosing below is off-label)
  2. Dose 0.5 mg/kg/dose (up to 30 mg/dose) IM or IV every 6 hours as needed

VII. Dosing Adult General

  1. Avoid oral Ketorolac (other NSAIDs are at least as effective orally, with fewer adverse effects)
  2. Ketorolac is typically as effective at lower dose than the originally approved doses (with fewer adverse effects)
    1. Use 30 mg IM (instead of 60 mg IM)
    2. Use 10 to 15 mg IV (instead of 30 mg IV)
      1. Ketorolac may have ceiling effect at 10 mg (at which higher doses offer no effect)
      2. Motov (2017) Ann Emerg Med 70(2):177-84 +PMID:27993418 [PubMed]
  3. Limit maximum daily dose to 60 mg/day (in divided doses)
    1. Age over 65 years
    2. Renal Impairment
    3. Weight under 50 kg (110 pounds)

VIII. Dosing: Adult Intramuscular dose

  1. Low dose (preferred, typical use)
    1. Single dose: 30 mg IM
    2. Repeated dose: 15 mg IM every 6 hours prn (<5 days)
    3. Maximum: 60 mg per day
  2. Regular dose (originally approved dosing)
    1. Single dose: 60 mg IM
    2. Repeated dose: 30 mg IM every 6 hours prn (<5 days)
    3. Maximum: 120 mg per day

IX. Dosing: Adult Intravenous Dose

  1. Lower dose (preferred, typical use)
    1. Ketorolac 15 mg IV every 6 hours as needed <(5 days) OR
    2. Ketorolac 10 mg IV every 6 hours as needed
      1. Dose 10 mg appears to be as effective as the 15 and 30 mg doses
      2. Analgesic ceiling dose may be 10 mg, above which are more adverse effects without benefit
      3. Motov (2017) Ann Emerg Med 70(2):177-84 +PMID:27993418 [PubMed]
  2. Regular dose (originally approved dosing, and may have no benefit over 10-15 mg dose)
    1. Ketorolac 30 mg IV every 6 hours prn (<5 days)

X. Dosing: Adult Oral dose (continuation of Parenteral dosing)

  1. Consider other NSAIDs which are typically as effective, with less Gastrointestinal Bleeding risk
  2. Maximum: 40 mg per day
  3. Low dose (preferred, if oral Ketorolac is used at all)
    1. Dose: 10 mg PO every 4 to 6 hours prn
  4. Regular dose
    1. First dose: 20 mg PO (two 10 mg tablets)
    2. Subsequent dosing: 10 mg PO q4-6 hours prn

XI. Dosing: Adult Intranasal

  1. Preparation: Ketorolac Tromethamine
  2. One spray delivers 15.75 mg of Ketorolac Tromethamine
  3. Use every 6-8 hours (maximum 4 times daily)
  4. Typical Dose: One spray each notsril
  5. Reduced Dose: One spray in one nostril
    1. Indicated in over age 65 years, weight <110 lbs or renal Impairment
  6. Local adverse effects
    1. See adverse effects below and NSAIDs for systemic effects
    2. Nasal discomfort
    3. Increased Lacrimation
    4. Throat irritation
  7. References
    1. Fitzgerald (2020) Crit Dec Emerg Med 34(10): 24

XII. Adverse Effects

  1. See NSAID
  2. Gastrointestinal Bleeding (Peptic Ulcer Disease)
    1. See NSAID Gastrointestinal Adverse Effects
    2. Among the highest Gastrointestinal Bleeding risks of any NSAID
  3. Exacerbation of Renal Insufficiency
    1. See NSAID Renal Adverse Effects
  4. Bleeding risk
    1. Higher risk of bleeding complications than with other NSAIDs (likely related to anti-Platelet activity)
    2. Avoid in postoperative patients with risk of bleeding complications (e.g. Tonsillectomy)

XIII. Safety

  1. See NSAID
  2. Considered safe in Lactation
  3. Avoid NSAIDs in pregnancy outside the first part of the second trimester (13 to 20 weeks)
    1. Teratogenic in first trimester
    2. Risk of premature ductus arteriosus closure in the fetus in third trimester
    3. Most NSAIDs carry a legacy system Pregnancy Category B or C designation (aside from third trimester)
      1. However, many obstetricians avoid NSAIDs entirely in pregnancy (even in second trimester)

XIV. Efficacy

  1. Most NSAIDs have equivalent efficacy to Parenteral Ketorolac (and to some Opioids)
  2. Equivalents to Toradol 60 mg IM
    1. Morphine 12 mg IM
    2. Most NSAIDS (and similar onset of action to IM Injection)
      1. Ibuprofen 800 mg orally
      2. Naprosyn 500 mg orally
  3. Advantages over Morphine in ER with blunt limb Trauma
    1. Toradol has longer duration
    2. Toradol less adverse effects
    3. Toradol IV more effective than Morphine IV
  4. References
    1. Rainer (2000) BMJ 321:1247-51 [PubMed]

XV. Resources

  1. Ketorolac Oral Tablets (DailyMed)
    1. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=688f5dec-a6db-43c6-a1f8-5df99d08d395
  2. Ketorolac Injectable Solution (DailyMed)
    1. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=8accbb78-fc64-45d5-69b0-35c23a1d2a2e

XVI. References

  1. (2012) Presc Lett 19(6): 33
  2. Turturro (1995) Ann Emerg Med 26:117-20 [PubMed]
  3. (2000) Med Lett Drugs Ther 42(1085): 73-78 [PubMed]
  4. Vadivelu (2015) Pain Pract 5(2):175-93 +PMID: 24738596 [PubMed]

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Related Studies

Cost: Medications

ketorolac (on 12/21/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
KETOROLAC 0.4% OPHTH SOLUTION Generic $9.45 per ml
KETOROLAC 0.5% OPHTH SOLUTION Generic $1.38 per ml
KETOROLAC 10 MG TABLET Generic $0.52 each
KETOROLAC 30 MG/ML VIAL Generic $1.36 per ml
KETOROLAC 60 MG/2 ML VIAL Generic $0.65 per ml
FPNotebook does not benefit financially from showing this medication data or their pharmacy links. This information is provided only to help medical providers and their patients see relative costs. Insurance plans negotiate lower medication prices with suppliers. Prices shown here are out of pocket, non-negotiated rates. See Needy Meds for financial assistance information. GoodRx is another tool for finding lower drug prices.

Ontology: Ketorolac (C0073631)

Definition (NCI) A synthetic pyrrolizine carboxylic acid derivative with anti-inflammatory, analgesic, and antipyretic activities. Ketorolac non-selective inhibits the enzymes cyclooxygenase 1 (COX-1) and COX-2. The inhibition of COX-2, up-regulated at sites of inflammation, prevents conversion of arachidonic acid to pro-inflammatory prostaglandins. The inhibition of COX-1 by this agent prevents the normal steady-state production of prostaglandins that play housekeeping roles in the protection of the gastrointestinal tract, the regulation of renal blood flow, and platelet aggregation. As a result, the inhibition of COX-1 may be associated with gastrointestinal toxicity, nephrotoxicity, and the inhibition of platelet aggregation.
Definition (MSH) A pyrrolizine carboxylic acid derivative structurally related to INDOMETHACIN. It is an NSAID and is used principally for its analgesic activity. (From Martindale The Extra Pharmacopoeia, 31st ed)
Definition (PDQ) A synthetic pyrrolizine carboxylic acid derivative with anti-inflammatory, analgesic and antipyretic properties. Ketorolac, a non-selective inhibitor of the cyclo-oxygenase (COX) enzyme, prevents the synthesis of prostaglandins and thromboxanes from arachidonic acid. COX enzymes exist in two isoforms; inhibition of the COX-2 enzyme produces the anti-inflammatory and analgesic whereas, inhibition of the COX-1 enzyme is associated with gastrointestinal side effects, nephrotoxicity and platelet de-aggregatory effects. Check for "http://www.cancer.gov/Search/ClinicalTrialsLink.aspx?id=40569&idtype=1" active clinical trials or "http://www.cancer.gov/Search/ClinicalTrialsLink.aspx?id=40569&idtype=1&closed=1" closed clinical trials using this agent. ("http://nciterms.nci.nih.gov:80/NCIBrowser/ConceptReport.jsp?dictionary=NCI_Thesaurus&code=C1219" NCI Thesaurus)
Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH D020910
SnomedCT 363609006, 108512006, 372501008
LNC LP18986-7, MTHU007199
English Ketorolac, 1H-Pyrrolizine-1-carboxylic acid, 5-benzoyl-2,3-dihydro, Ketorolac [Chemical/Ingredient], Ketorolac product (substance), Ketorolac product, KETOROLAC, anti-inflammatory nonsteroidal ketorolac, ketorolac (medication), ketorolac, Ketorolac (product), Ketorolac (substance)
Swedish Ketorolak
Czech ketorolak
Finnish Ketorolaakki
Russian KETOROLAK, КЕТОРОЛАК
Spanish ketorolac (producto), cetorolaco, ketorolaco (producto), ketorolac, ketorolac (sustancia), ketorolaco (sustancia), ketorolaco, Ketorolaco
Polish Ketorolak
French Kétorolac
German Ketorolac
Italian Ketorolac
Portuguese Cetorolaco
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Toradol (C0146226)

Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH D020911
English Toradol, toradol
Derived from the NIH UMLS (Unified Medical Language System)

Related Topics in Analgesic Medications

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