Is it safe to administer intramuscular (IM) Toradol (ketorolac) to a patient who had a quadruple bypass 6 years ago?

From the Guidelines

Administering intramuscular (IM) Toradol (ketorolac) to a patient with a history of quadruple bypass surgery 6 years ago is generally not recommended due to significant cardiovascular risks. Ketorolac, a potent non-steroidal anti-inflammatory drug (NSAID), increases the risk of cardiovascular events including heart attack, stroke, and thrombotic events, particularly in patients with established cardiovascular disease 1. For patients with prior coronary artery bypass grafting, alternative pain management options should be considered first, such as acetaminophen, which has been shown to be a valid and effective option in a multimodal regimen for postoperative pain management 1. If pain control is absolutely necessary and other options have failed, tramadol or short-term, low-dose opioids would be safer alternatives. The cardiovascular risks of NSAIDs like ketorolac are related to their COX-2 inhibition, which reduces production of vasodilatory and antithrombotic prostacyclin while maintaining production of thromboxane A2, creating a prothrombotic state. Additionally, NSAIDs can interfere with the cardioprotective effects of aspirin that the patient may be taking as part of their post-bypass regimen. Some key points to consider when managing pain in patients with a history of cardiovascular disease include:

• Using acetaminophen as a first-line option for pain management 1
• Avoiding the use of NSAIDs, including ketorolac, due to their increased risk of cardiovascular events 1
• Considering alternative pain management options, such as tramadol or short-term, low-dose opioids, if acetaminophen is not effective 1
• Consulting with the patient's cardiologist before administering any NSAID, especially if the patient is experiencing acute pain requiring immediate intervention.

From the FDA Drug Label

Cardiovascular Thrombotic Events Clinical trials of several COX-2 selective and nonselective NSAIDs of up to three years duration have shown an increased risk of serious cardiovascular (CV) thrombotic events, including myocardial infarction (MI) and stroke, which can be fatal Patients with known CV disease or risk factors had a higher absolute incidence of excess serious CV thrombotic events, due to their increased baseline rate. Status Post Coronary Artery Bypass Graft (CABG) Surgery Two large, controlled clinical trials of a COX-2 selective NSAID for the treatment of pain in the first 10 to 14 days following CABG surgery found an increased incidence of myocardial infarction and stroke. Post-MI Patients Observational studies conducted in the Danish National Registry have demonstrated that patients treated with NSAIDs in the post-MI period were at increased risk of reinfarction, CV-related death, and all-cause mortality beginning in the first week of treatment

Administration of IM Toradol to a patient who had a quadruple bypass 6 years ago is not recommended due to the increased risk of serious cardiovascular thrombotic events, including myocardial infarction and stroke.

• The patient has a history of cardiovascular disease, which increases the absolute incidence of excess serious CV thrombotic events.
• Although it has been 6 years since the quadruple bypass, the risk of CV thrombotic events still exists, especially with the use of NSAIDs like ketorolac tromethamine.
• The benefits of using IM Toradol in this patient do not outweigh the risks of recurrent CV thrombotic events 2.

From the Research

Safety of Administering IM Toradol to a Patient with a History of Quad Bypass

• The safety of administering intramuscular (IM) Toradol (ketorolac) to a patient who had a quadruple bypass 6 years ago is a concern due to the potential risks of bleeding and cardiovascular events.
• However, studies have shown that ketorolac can be used safely in patients after coronary artery bypass grafting (CABG) surgery, with some studies suggesting that it may even improve graft patency 3.
• A study published in 2016 found that continuous infusion ketorolac was not associated with an increased risk of mortality, myocardial infarction, or bleeding events in postoperative CABG patients 4.
• Another study published in 2011 found that ketorolac use after CABG was associated with a lower rate of angiographically proven graft closure, suggesting a potential benefit for graft patency 3.
• It is essential to consider the individual patient's risk factors, such as age, diabetes, and peripheral vascular disease, when making decisions about administering IM Toradol 5.
• Long-term follow-up studies have shown that patients who undergo CABG surgery can have a significant life expectancy, with some studies reporting up to 40-year follow-up 6, 7.

Key Considerations

• Patient's individual risk factors, such as age and comorbidities, should be taken into account when deciding to administer IM Toradol.
• The potential benefits of ketorolac, such as improved graft patency, should be weighed against the potential risks of bleeding and cardiovascular events.
• Close monitoring of the patient's condition and adjustment of the treatment plan as needed is crucial to ensure safe and effective use of IM Toradol.