II. Class
- 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
III. Precautions
- See NSAIDs
- Do not use longer than 5 days
- Do not repeat two Toradol courses back to back
IV. Indications
- Analgesia for moderate to severe acute pain
- Alternative to Narcotic Analgesic
V. Contraindications
- Peptic Ulcer Disease
- Renal Insufficiency
- Acute or chronic bleeding risk
- Hypersensitivity to Aspirin or other NSAID
- Age <2 years old
VI. Dosing: Indications for using lower dose
- Age over 65 years
- Renal Impairment
- Weight under 50 kg (110 pounds)
VII. Dosing: Intramuscular dose
- Regular dose
- Single dose: 60 mg IM
- Repeated dose: 30 mg IM every 6 hours prn (<5 days)
- Maximum: 120 mg per day
- Low dose
- Single dose: 30 mg IM
- Repeated dose: 15 mg IM every 6 hours prn (<5 days)
- Maximum: 60 mg per day
VIII. Dosing: Intravenous dose
- Regular dose: 30 mg IV every 6 hours prn (<5 days)
- Low dose: 15 mg IV every 6 hours prn <(5 days)
- Very low dose: 10 mg IV every 6 hours prn
- 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]
IX. Dosing: Oral dose (continuation of parenteral dosing)
- Consider other NSAIDs which are typically as effective, with less Gastrointestinal Bleeding risk
- Maximum: 40 mg per day
- Regular dose
- First dose: 20 mg PO (two 10 mg tablets)
- Subsequent dosing: 10 mg PO q4-6 hours prn
- Low dose
- Dose: 10 mg PO q4-6 hours prn
X. Dosing: 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 NSAIDs for systemic effects
- Nasal discomfort
- Increased Lacrimation
- Throat irritation
- References
- Fitzgerald (2020) Crit Dec Emerg Med 34(10): 24
XI. Adverse Effects
- See NSAIDs
-
Gastrointestinal Bleeding (Peptic Ulcer Disease)
- See NSAID Gastrointestinal Adverse Effects
- Among the highest Gastrointestinal Bleeding risks of any NSAID
- Exacerbation of Renal Insufficiency
- Bleeding risk
XII. Efficacy
- Most NSAIDs have equivalent efficacy to parenteral Ketorolac (and to some Opioids)
- Equivalents to Toradol 60 mg IM
- Morphine 12 mg IM
- Most NSAIDS (and similar onset of action to IM Injection)
- 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
XIII. References
Images: Related links to external sites (from Bing)
Related Studies
| ketorolac (on 5/17/2017 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
| KETOROLAC 0.4% OPHTH SOLUTION | Generic | $9.98 per ml |
| KETOROLAC 0.5% OPHTH SOLUTION | Generic | $1.51 per ml |
| KETOROLAC 10 MG TABLET | Generic | $0.99 each |
| KETOROLAC 30 MG/ML VIAL | Generic | $3.48 per ml |
| KETOROLAC 60 MG/2 ML VIAL | Generic | $1.33 per ml |
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 |
Ontology: Toradol (C0146226)
| Concepts | Pharmacologic Substance (T121) , Organic Chemical (T109) |
| MSH | D020911 |
| English | Toradol, toradol |
