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Ketorolac
Aka: Ketorolac, Toradol, SPRIX
- 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
- Precautions
- See NSAIDs
- Do not use longer than 5 days
- Do not repeat two Toradol courses back to back
- Indications
- Analgesia for moderate to severe acute pain
- Alternative to Narcotic Analgesic
- Contraindications
- Peptic Ulcer Disease
- Renal Insufficiency
- Acute or chronic bleeding risk
- Hypersensitivity to Aspirin or other NSAID
- Age <2 years old
- Dosing: Indications for using lower dose
- Age over 65 years
- Renal Impairment
- Weight under 50 kg (110 pounds)
- 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
- 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]
- 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
- 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
- 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
- See NSAID Renal Adverse Effects
- Bleeding risk
- 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)
- 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]
- 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]