From the FDA Drug Label
Although these results do not indicate a significant interaction between ketorolac tromethamine and warfarin or heparin, the administration of ketorolac tromethamine to patients taking anticoagulants should be done extremely cautiously, and patients should be closely monitored (see WARNINGS and PRECAUTIONS, Hematologic Effect) The effects of warfarin and NSAIDs, in general, on GI bleeding are synergistic, such that the users of both drugs together have a risk of serious GI bleeding higher than the users of either drug alone.
Key Considerations:
- The administration of Toradol (Ketorolac) to patients taking anticoagulants like Warfarin should be done extremely cautiously.
- Patients should be closely monitored for signs of bleeding or other adverse effects.
- The risk of serious GI bleeding is higher when using both Warfarin and NSAIDs like Toradol together.
Clinical Decision: It is recommended to avoid or use with caution Toradol in patients taking Warfarin due to the increased risk of bleeding and other potential interactions 1.
From the Research
Yes, Toradol (ketorolac) should generally be avoided in patients taking warfarin. This combination significantly increases the risk of bleeding complications due to their overlapping mechanisms. Warfarin is an anticoagulant that inhibits vitamin K-dependent clotting factors, while Toradol is a nonsteroidal anti-inflammatory drug (NSAID) that inhibits platelet aggregation and can cause gastric irritation and ulceration. When used together, they create a dangerous "double hit" on hemostasis - warfarin prevents clot formation while Toradol both impairs platelet function and potentially creates bleeding sites in the gastrointestinal tract.
Key Points to Consider
- The risk of bleeding is significantly increased when warfarin is combined with NSAIDs, including Toradol, as shown in a systematic review and meta-analysis 2.
- The odds ratio for gastrointestinal bleeding when exposed to warfarin and an NSAID was 1.98 (95% confidence interval: 1.55-2.53) 2.
- A more recent study found that the combination of warfarin and NSAIDs, including COX-2 inhibitors, increases the risk of general bleeding (OR = 1.58,95% CI: 1.18-2.12) and gastrointestinal bleeding (OR = 1.98,95% CI: 1.55-2.53) 2.
- Another study published in 2021 found that NSAIDs, including Toradol, increase the risk of clinically relevant bleeding when added to warfarin therapy (OR = 1.83,95% CI: 1.29-2.59) 3.
Recommendations for Pain Management
- For pain management in patients on warfarin, safer alternatives include acetaminophen (Tylenol) for mild to moderate pain or, if stronger analgesia is needed, carefully monitored short-term opioid medications.
- If an NSAID is absolutely necessary, it should only be used under close medical supervision with frequent INR monitoring and for the shortest possible duration.
- It is essential to weigh the benefits and risks of using Toradol in patients taking warfarin and to consider alternative pain management options to minimize the risk of bleeding complications.