Ketorolac

Aka: Ketorolac, Toradol

1. Class
   1. NSAID in the Acetic acid class (Pyrrolo-pyrrole)
2. Precautions
   1. Do not use longer than 5 days
   2. Do not repeat 2 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. 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. Adverse Effects
   1. Gastrointestinal Bleeding (Peptic Ulcer Disease)
      1. See NSAID Gastrointestinal Adverse Effects
      2. Among the highest Gastrointestinal Bleeding risks of any NSAID
   2. Exacerbation of Renal Insufficiency
      1. See NSAID Renal Adverse Effects
   3. Bleeding risk
10. 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]
11. 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]