Contraindications for Toradol (Ketorolac)
Toradol (ketorolac) is absolutely contraindicated in patients with active peptic ulcer disease, recent gastrointestinal bleeding or perforation, history of peptic ulcer disease, advanced renal impairment, risk of renal failure, suspected/confirmed cerebrovascular bleeding, hemorrhagic diathesis, incomplete hemostasis, high bleeding risk, coronary artery bypass graft (CABG) surgery, hypersensitivity to NSAIDs, labor and delivery, and concurrent use with other NSAIDs or aspirin. 1
Major Contraindications
Gastrointestinal Contraindications
- Active peptic ulcer disease
- Recent gastrointestinal bleeding or perforation
- History of peptic ulcer disease or gastrointestinal bleeding
- High risk for GI toxicity (age >60 years, history of peptic ulcer disease, significant alcohol use, major organ dysfunction) 2, 1
Cardiovascular Contraindications
- Coronary artery bypass graft (CABG) surgery setting
- History of cardiovascular disease or risk factors for cardiovascular disease
- Patients taking anticoagulants (warfarin, heparin) due to significantly increased bleeding risk 2, 1
Renal Contraindications
- Advanced renal impairment
- Risk of renal failure due to volume depletion
- Age >60 years with compromised fluid status
- Interstitial nephritis, papillary necrosis
- Concomitant administration of nephrotoxic drugs (cyclosporin, cisplatin) 2, 1
Bleeding Risk Contraindications
- Suspected or confirmed cerebrovascular bleeding
- Hemorrhagic diathesis
- Incomplete hemostasis
- High risk of bleeding
- Thrombocytopenia or bleeding disorders 2, 1
Hypersensitivity Contraindications
- Previous hypersensitivity to ketorolac
- Allergic manifestations to aspirin or other NSAIDs
- Aspirin/NSAID-induced asthma
- History of asthma, rhinitis, and nasal polyps (increased risk of bronchospastic reactions) 2, 3
Other Contraindications
- Pregnancy
- Labor and delivery (may adversely affect fetal circulation and inhibit uterine contractions)
- Concurrent use with other NSAIDs or aspirin (cumulative risk of side effects)
- Intrathecal or epidural administration (contraindicated due to alcohol content)
- Use for >5 days (maximum treatment duration) 1, 4
Special Populations Requiring Caution
- Patients ≥65 years old (require dose adjustment)
- Patients <50 kg (110 lbs) (require dose adjustment)
- Patients with moderately elevated serum creatinine 1
Monitoring Recommendations
For patients receiving ketorolac, baseline monitoring should include:
- Blood pressure
- BUN, creatinine
- Liver function studies (alkaline phosphatase, LDH, SGOT, SGPT)
- CBC and fecal occult blood 2
Important Warnings
Ketorolac should only be used for short-term management (≤5 days) of moderately severe acute pain. It is not indicated for minor or chronic painful conditions 1. The risk of adverse events increases significantly with:
Ketorolac has been associated with a significantly higher risk of gastrointestinal complications (RR 24.7) compared to other NSAIDs, making proper patient selection critical 5.
When used according to current dosage guidelines and with careful patient selection, ketorolac can be a useful alternative to opioids for moderate to severe pain, but its contraindications must be strictly observed to minimize potentially serious adverse events.