What are the risks and recommendations for using Toradol (Ketorolac) and Eliquis (Apixaban) together?

From the Guidelines

Using Toradol (ketorolac) and Eliquis (apixaban) together is generally not recommended due to a significantly increased risk of bleeding. This combination should be avoided whenever possible as both medications affect blood clotting through different mechanisms, creating a dangerous additive effect. Eliquis is an anticoagulant that directly inhibits factor Xa in the clotting cascade, while Toradol is a nonsteroidal anti-inflammatory drug (NSAID) that reduces clotting by inhibiting platelet aggregation. When used together, patients face higher risks of gastrointestinal bleeding, intracranial hemorrhage, and bleeding at other sites.

Some key points to consider when evaluating the risks of this combination include:

• The mechanism of action of both drugs and how they interact to increase the risk of bleeding
• The patient's individual risk factors for bleeding, such as age, kidney function, and history of gastrointestinal bleeding or ulcers
• The potential benefits of using Toradol for pain management versus the increased risk of bleeding when combined with Eliquis

According to the study published in Circulation: Arrhythmia and Electrophysiology 1, experts recommend avoiding the combination of apixaban with strong CYP3A4 and P-gp inhibitors. However, this study does not specifically address the interaction between Toradol and Eliquis.

In situations where the combination cannot be avoided, treatment duration with Toradol should be limited to the shortest possible time (ideally no more than 5 days), the lowest effective dose should be used, and patients should be closely monitored for signs of bleeding such as unusual bruising, black stools, or blood in urine. Patients should also be educated to report any unusual bleeding immediately. If pain management is needed for a patient on Eliquis, acetaminophen (Tylenol) is generally a safer alternative.

It's also important to note that the study published in Chest 1 discusses the risks and benefits of antithrombotic therapy for VTE disease, but does not specifically address the interaction between Toradol and Eliquis. However, it does provide information on the risks of bleeding associated with anticoagulant therapy, which can inform decision-making when considering the use of Toradol in patients taking Eliquis.

Overall, the decision to use Toradol in a patient taking Eliquis should be made with caution and careful consideration of the potential risks and benefits. The combination of Toradol and Eliquis should be avoided whenever possible, and alternative pain management options should be considered.

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 concurrent use of ketorolac tromethamine and therapy that affects hemostasis, including prophylactic low-dose heparin (2500 to 5000 units q12h), warfarin and dextrans have not been studied extensively, but may also be associated with an increased risk of bleeding Apixaban can cause serious, potentially fatal, bleeding. Promptly evaluate signs and symptoms of blood loss.

The use of Toradol (Ketorolac) and Eliquis (Apixaban) together may increase the risk of bleeding complications. Key considerations include:

• Increased risk of bleeding due to the concurrent use of anticoagulants and ketorolac tromethamine
• Potential for serious, potentially fatal, bleeding with apixaban
• Need for cautious administration of concomitant therapy
• Importance of promptly evaluating signs and symptoms of blood loss 2 3

From the Research

Risks of Using Toradol (Ketorolac) and Eliquis (Apixaban) Together

• The use of Toradol (Ketorolac) and Eliquis (Apixaban) together may increase the risk of bleeding due to their individual mechanisms of action 4, 5.
• Ketorolac has antiplatelet properties, which can prolong bleeding time and inhibit platelet aggregation 4.
• Apixaban is a direct oral anticoagulant that works by inhibiting factor Xa, increasing the risk of bleeding 5, 6.
• The combination of these two medications may increase the risk of major bleeding, particularly gastrointestinal bleeding 7, 8.

Recommendations for Using Toradol (Ketorolac) and Eliquis (Apixaban) Together

• Patients should be closely monitored for signs of bleeding when using Toradol and Eliquis together 4, 5.
• The dose and duration of Toradol should be minimized to reduce the risk of bleeding 7, 8.
• Alternative pain management options should be considered for patients taking Eliquis, especially if they have a history of bleeding or are at high risk of bleeding 5, 6.
• Healthcare providers should weigh the benefits and risks of using Toradol and Eliquis together and consider alternative treatments if necessary 4, 5, 8.