Ketorolac (Toradol) Dosing Guidelines and Precautions for Pain Management
Ketorolac (Toradol) should be limited to short-term use of no more than 5 days due to significant risks of renal, gastrointestinal, and bleeding complications. 1, 2
Dosing Guidelines
Parenteral (IM/IV) Administration
Single-Dose Treatment:
- Patients <65 years: 60 mg IM or 30 mg IV
- Patients ≥65 years, renally impaired, or <50 kg: 30 mg IM or 15 mg IV 1
Multiple-Dose Treatment:
- Patients <65 years: 30 mg IV/IM every 6 hours (maximum 120 mg/day)
- Patients ≥65 years, renally impaired, or <50 kg: 15 mg IV/IM every 6 hours (maximum 60 mg/day) 1
Oral Administration (Only as continuation of IV/IM therapy)
- Patients 17-64 years: 20 mg PO once, then 10 mg every 4-6 hours PRN (maximum 40 mg/day)
- Patients ≥65 years, renally impaired, or <50 kg: 10 mg PO once, then 10 mg every 4-6 hours PRN (maximum 40 mg/day) 2
Major Precautions and Contraindications
Absolute Contraindications
- History of peptic ulcer disease
- GI bleeding or perforation
- Advanced renal impairment or risk of renal failure
- Cerebrovascular bleeding
- Hemorrhagic diathesis/coagulation disorders
- Pregnancy
- Concurrent use with aspirin or other NSAIDs 3, 1
High-Risk Populations Requiring Caution
- Elderly patients (≥65 years): Higher risk of adverse effects; use reduced dosing
- Patients with renal impairment: Risk of acute renal failure
- Patients <50 kg: Require dose reduction
- Patients with cardiovascular disease: Risk of thrombotic events
- Patients on anticoagulants: Increased bleeding risk 3, 4
Monitoring Requirements
Before Initiation
- Baseline blood pressure
- Renal function tests (BUN, creatinine)
- Liver function tests
- Complete blood count
- Coagulation profile
- Fecal occult blood test 3
During Treatment
- Monitor for signs of GI bleeding
- Monitor renal function
- Assess for edema, hypertension
- Watch for signs of hypersensitivity reactions 4, 5
Key Adverse Effects to Monitor
Gastrointestinal
- GI upset, bleeding, perforation
- Risk increases with higher doses and longer duration of therapy 4
Renal
- Acute renal failure (usually reversible upon discontinuation)
- Discontinue if BUN or creatinine doubles or hypertension develops/worsens 3, 6
Hematologic
- Inhibition of platelet aggregation
- Increased bleeding time
- Increased risk of surgical site bleeding 4, 7
Other
- Edema
- Drowsiness, dizziness
- Increased diaphoresis 3
Clinical Pearls
- Duration limitation: Total duration of ketorolac therapy (IV/IM plus oral) must not exceed 5 days 1, 2
- Hypovolemia correction: Correct hypovolemia before administering ketorolac 1
- Administration technique: IV bolus must be given over no less than 15 seconds; IM injections should be given slowly and deeply into the muscle 1
- Onset and duration: Analgesic effect begins in ~30 minutes with maximum effect in 1-2 hours; duration of effect is usually 4-6 hours 1, 8
- Opioid-sparing effect: When combined with opioids, ketorolac can reduce opioid requirements by 25-50%, potentially reducing opioid-related adverse effects 5
Special Considerations in Specific Populations
Pediatric Patients
- Not FDA approved for children under 17 years for oral formulation 2
- For postoperative pain in children, IV dosing of 0.5 mg/kg has been studied, but caution is warranted 7
Cancer Pain Management
- May be considered as part of multimodal analgesia in cancer pain
- Particularly beneficial in pain resulting from bone metastases 5
- Monitor closely for toxicities in patients receiving chemotherapy due to potential additive nephrotoxicity 3
By following these guidelines and precautions, ketorolac can be an effective short-term analgesic while minimizing the risk of serious adverse events.