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]

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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