Can Toradol (ketorolac) and aspirin be administered concurrently?

From the Guidelines

It is strongly advised against administering Toradol (ketorolac) and aspirin concurrently due to the significantly increased risk of gastrointestinal bleeding, ulceration, and perforation, as well as potential interference with aspirin's cardioprotective effects. Both medications are nonsteroidal anti-inflammatory drugs (NSAIDs) that work through similar mechanisms, and using them together does not provide additional therapeutic benefit while substantially increasing the risk of serious side effects 1. The combination can lead to a higher risk of complications, particularly in patients with certain conditions such as kidney disease, heart failure, or a history of gastrointestinal bleeding.

When considering pain management, it is recommended to use either Toradol or aspirin individually, not both simultaneously. For patients already on low-dose aspirin for cardiovascular protection, temporary discontinuation of aspirin may be considered when short-term Toradol is necessary, but this decision should be made under the guidance of a healthcare provider who can evaluate individual risks and benefits 1. The FDA cautions that the concomitant use of an NSAID with aspirin may reduce the cardioprotective efficacy of aspirin, and concomitant use of an NSAID and low-dose aspirin may increase the risk of gastrointestinal bleeding 1.

Key considerations include:

• Increased risk of gastrointestinal bleeding and perforation
• Potential interference with aspirin's cardioprotective effects
• Higher risk of complications in patients with certain pre-existing conditions
• Recommendation to use either medication individually for pain management
• Need for healthcare provider evaluation for temporary discontinuation of aspirin when necessary 1.

From the FDA Drug Label

Ketorolac tromethamine is contraindicated in patients currently receiving aspirin or NSAIDs because of the cumulative risks of inducing serious NSAID-related adverse events. The concomitant use of ketorolac tromethamine and probenecid is contraindicated. The concomitant use of ketorolac tromethamine and pentoxifylline is contraindicated. Aspirin When ketorolac tromethamine is administered with aspirin, its protein binding is reduced, although the clearance of free ketorolac tromethamine is not altered The clinical significance of this interaction is not known; however, as with other NSAIDs, concomitant administration of ketorolac tromethamine and aspirin is not generally recommended because of the potential of increased adverse effects

Concurrent administration of Toradol (ketorolac) and aspirin is not recommended due to the potential of increased adverse effects, including serious NSAID-related adverse events.

• The FDA drug label explicitly states that ketorolac tromethamine is contraindicated in patients currently receiving aspirin or NSAIDs.
• The use of ketorolac tromethamine with aspirin may increase the risk of adverse effects, although the clinical significance of this interaction is not fully known 2.

From the Research

Administration of Toradol (Ketorolac) and Aspirin

• The provided studies do not directly address the concurrent administration of Toradol (ketorolac) and aspirin 3, 4, 5, 6, 7.
• However, the studies suggest that the use of non-steroidal anti-inflammatory drugs (NSAIDs), including ketorolac, is associated with an increased risk of gastrointestinal toxicity, and that this risk is further increased when NSAIDs are combined with aspirin 4, 6, 7.
• One study found that ketorolac had the highest risk of upper gastrointestinal bleeding among non-aspirin NSAIDs, with an adjusted relative risk of 14.4 (95% CI 5.2 to 39.9) 6.
• Another study found that the use of a non-selective NSAID, such as naproxen, with a proton pump inhibitor (PPI) may be at least as effective as the use of a COX-2 selective inhibitor in preventing the recurrence of ulcer complications, and that the choice of NSAID should be tailored to the gastrointestinal and cardiovascular risks in the patient 4.
• The studies suggest that the use of a PPI or misoprostol may be beneficial in reducing the risk of gastrointestinal toxicity associated with NSAID use, including when NSAIDs are combined with aspirin 3, 4, 7.

Gastrointestinal and Cardiovascular Risks

• The studies highlight the importance of considering both gastrointestinal and cardiovascular risks when selecting an NSAID for patients, particularly those who require concomitant aspirin therapy 4, 5, 6.
• The use of aspirin with NSAIDs, including ketorolac, may increase the risk of gastrointestinal toxicity, and this risk should be carefully considered when making treatment decisions 4, 6, 7.