Ketorolac

Aka: Ketorolac, Toradol, SPRIX

1. 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
2. Precautions
   1. See NSAIDs
   2. Do not use longer than 5 days
   3. Do not repeat two Toradol courses back to back
3. Indications
   1. Analgesia for moderate to severe acute pain
   2. Alternative to Narcotic Analgesic
4. 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
5. Dosing: Indications for using lower dose
   1. Age over 65 years
   2. Renal Impairment
   3. Weight under 50 kg (110 pounds)
6. 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
7. 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]
8. 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
9. 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
10. Adverse Effects
    1. See NSAIDs
    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
11. 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]
12. 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]