II. Class

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

III. Precautions

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

IV. Indications

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

V. Contraindications

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

VI. Dosing: Indications for using lower dose

  1. Age over 65 years
  2. Renal Impairment
  3. Weight under 50 kg (110 pounds)

VII. Dosing: Intramuscular dose

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

VIII. Dosing: Intravenous dose

  1. Regular dose: 30 mg IV every 6 hours prn (<5 days)
  2. Low dose: 15 mg IV every 6 hours prn <(5 days)
  3. Very low dose: 10 mg IV every 6 hours prn
    1. 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]

IX. Dosing: 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. Regular dose
    1. First dose: 20 mg PO (two 10 mg tablets)
    2. Subsequent dosing: 10 mg PO q4-6 hours prn
  4. Low dose
    1. Dose: 10 mg PO q4-6 hours prn

X. Dosing: 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. 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]

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Related Studies

Cost: Medications

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