From the FDA Drug Label
Patients on therapeutic doses of anticoagulants (e.g., heparin or dicumarol derivatives) have an increased risk of bleeding complications if given ketorolac tromethamine concurrently; therefore, physicians should administer such concomitant therapy only extremely cautiously
The use of 15mg IV Toradol (ketorolac) in a patient who received a one-time dose of 8000 units of tinzaparin (a low molecular weight heparin, an anticoagulant) within the last 12 hours may increase the risk of bleeding complications. Caution is advised when using ketorolac in patients on anticoagulant therapy, including tinzaparin. The patient should be carefully monitored for signs of bleeding. 1
From the Research
Administering 15mg of IV Toradol (ketorolac) to a patient who received 8000 units of tinzaparin within the last 12 hours is generally not recommended due to increased bleeding risk. These medications should ideally be separated by at least 24 hours. Toradol is a non-steroidal anti-inflammatory drug (NSAID) that inhibits platelet aggregation, while tinzaparin is a low molecular weight heparin anticoagulant. When used together, they can have additive effects on bleeding risk. If pain management is necessary for this patient, consider alternative analgesics such as acetaminophen (up to 1000mg every 6 hours, not exceeding 4000mg daily) or, if stronger analgesia is required, opioid medications which don't affect coagulation. The patient should be monitored for any signs of bleeding if analgesics must be administered. The concern stems from the pharmacological mechanism where NSAIDs like ketorolac affect platelet function while anticoagulants like tinzaparin inhibit clotting factor activity, potentially compromising hemostasis from multiple pathways simultaneously, as seen in studies such as 2 where the safety of weight-adjusted tinzaparin was evaluated. However, the most recent and highest quality study, 3, which evaluated the use of intensive-dose tinzaparin in hospitalized COVID-19 patients, did not directly address the interaction between tinzaparin and NSAIDs like ketorolac, but it did highlight the importance of careful anticoagulation management to minimize bleeding risks. Given the potential for increased bleeding risk, it is prudent to exercise caution and avoid the concurrent use of these medications whenever possible, prioritizing the patient's safety and minimizing potential harm to their morbidity, mortality, and quality of life. Key considerations include:
- The mechanism of action of both medications and their potential to increase bleeding risk
- The timing of administration and the ideal separation of these medications to minimize risk
- Alternative analgesic options that do not affect coagulation
- The importance of monitoring for signs of bleeding in patients who must receive these medications concurrently. Ultimately, the decision to administer these medications together should be made with caution and careful consideration of the patient's individual risk factors and clinical status, as supported by studies like 3.