Is Toradol (ketorolac) contraindicated in patients with a history of cerebral vascular accident (CVA)?

Ketorolac (Toradol) is Contraindicated in Patients with Suspected or Confirmed Cerebrovascular Bleeding or CVA

Ketorolac is absolutely contraindicated in patients with suspected or confirmed cerebrovascular bleeding, hemorrhagic diathesis, incomplete hemostasis, and those at high risk of bleeding, which includes patients with a history of CVA. 1

Mechanism and Risk

Ketorolac is a potent non-steroidal anti-inflammatory drug (NSAID) with strong analgesic properties that works by inhibiting prostaglandin synthesis. This mechanism leads to several important effects that increase stroke risk:

• Platelet inhibition: Ketorolac significantly inhibits platelet function, which can worsen bleeding in patients with cerebrovascular events 1
• Increased stroke risk: Research has demonstrated that ketorolac use is associated with an increased risk of both ischemic and hemorrhagic stroke 2
• Particularly high risk with parenteral administration: Parenteral ketorolac carries a strikingly high risk with odds ratios of 3.92 for ischemic stroke and 5.98 for hemorrhagic stroke 2

FDA Contraindications

The FDA drug label for ketorolac explicitly states that it is contraindicated in:

• Patients with suspected or confirmed cerebrovascular bleeding
• Patients with hemorrhagic diathesis or incomplete hemostasis
• Those at high risk of bleeding 1

Management Considerations for CVA Patients

For patients with a history of CVA requiring pain management:

1. Avoid all NSAIDs including ketorolac in patients with recent CVA
2. Consider alternative analgesics that don't affect platelet function or increase bleeding risk
3. Follow stroke management guidelines which recommend antiplatelet therapy with aspirin alone, clopidogrel alone, or aspirin plus extended-release dipyridamole for secondary stroke prevention 3

Special Considerations

• The contraindication is especially important in patients with hemorrhagic stroke, where any medication affecting coagulation could worsen outcomes
• Even in patients with ischemic stroke, the risk of hemorrhagic transformation makes ketorolac use dangerous
• The American Heart Association/American Stroke Association guidelines emphasize careful management of antithrombotic therapy in stroke patients, and NSAIDs like ketorolac can interfere with this management 3

In summary, ketorolac should not be used in patients with a history of CVA due to its platelet inhibition properties and the significant increased risk of both ischemic and hemorrhagic stroke associated with its use.