From the Guidelines
Toradol (ketorolac) should generally be avoided in patients who have had bariatric surgery due to the increased risk of gastric and intestinal ulcers associated with non-steroidal anti-inflammatory drugs (NSAIDs) in this population. This is particularly concerning in bariatric surgery patients who already have altered gastrointestinal anatomy, putting them at higher risk for marginal ulcers at surgical anastomosis sites. The use of NSAIDs like ketorolac can significantly increase this risk, as noted in various studies 1.
For pain control in bariatric surgery patients, the following options can be considered:
- Acetaminophen (up to 3000 mg daily in divided doses) is typically the first-line non-opioid option, as it is effective for pain management without the gastrointestinal risks associated with NSAIDs 1.
- If additional pain control is needed, opioid medications may be used cautiously for short periods, with careful monitoring for respiratory depression and constipation.
- Tramadol (50-100 mg every 6 hours as needed) may be considered as an intermediate option, although its use should be approached with caution due to its potential for abuse and side effects.
- Liquid or chewable formulations of pain medications may be preferred in the early post-operative period when patients have difficulty swallowing pills.
It is essential to consult with the bariatric surgeon before administering any pain medications to these patients, as individual circumstances may vary. The goal is to balance effective pain management with the need to minimize risks, particularly those related to gastrointestinal complications in this vulnerable population.
From the FDA Drug Label
KETOROLAC TROMETHAMINE INJECTION Ketorolac tromethamine injection may be used as a single or multiple dose on a regular or “prn” schedule for the management of moderately severe, acute pain that requires analgesia at the opioid level, usually in a postoperative setting.
Therapy should always be initiated with intravenous or intramuscular dosing of ketorolac tromethamine, and oral ketorolac tromethamine is to be used only as continuation treatment, if necessary
The total combined duration of use of ketorolac tromethamine injection and oral ketorolac tromethamine is not to exceed 5 days of use because of the potential of increasing the frequency and severity of adverse reactions associated with the recommended doses
The FDA drug label does not answer the question.
From the Research
Administration of IM Toradol for Pain Control after Bariatric Surgery
- The use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as toradol (ketorolac) after bariatric surgery has been a topic of discussion due to concerns about increased gastric bleeding 2.
- However, a study published in 2019 found that the use of ketorolac as an adjunct to opioids for post-operative pain management after bariatric surgery was associated with a shorter hospital length of stay and did not increase the risk of post-operative bleeding complications 3.
- Another study published in 2021 found that NSAID use after sleeve gastrectomy was common, with 64.5% of respondents reporting some NSAID use after surgery, and no cases of sleeve complications secondary to NSAID use were identified 4.
- It is worth noting that the use of intravenous acetaminophen has been shown to decrease opioid consumption in patients after bariatric surgery, which may be a useful alternative or adjunct to NSAIDs for pain management 5, 6.
- Overall, the evidence suggests that IM toradol may be considered for pain control after bariatric surgery, but its use should be carefully evaluated and monitored due to the potential risks associated with NSAID use in this population 2, 3, 4.