What is the recommended frequency and duration for Toradol (ketorolac) injections?

Safe Administration Frequency of Toradol (Ketorolac) Injections

Toradol (ketorolac) injections should not be used for more than 5 consecutive days due to significant risks of renal, gastrointestinal, and bleeding complications. 1, 2

Dosing Guidelines

Standard Dosing

• Maximum duration: 5 days (absolute maximum) 1, 3
• Intramuscular dosing:
  • Patients <65 years: 60 mg single dose or 30 mg every 6 hours
  • Patients ≥65 years, renally impaired, or <50 kg: 30 mg single dose or 15 mg every 6 hours
• Intravenous dosing:
  • Patients <65 years: 30 mg single dose or 30 mg every 6 hours
  • Patients ≥65 years, renally impaired, or <50 kg: 15 mg single dose or 15 mg every 6 hours
• Maximum daily dose:
  • Patients <65 years: 120 mg
  • Patients ≥65 years, renally impaired, or <50 kg: 60 mg 1

Important Safety Considerations

Contraindications

• History of gastrointestinal bleeding or ulceration
• Renal impairment or risk of renal failure
• Compromised hemostasis or bleeding disorders
• Hypersensitivity to aspirin or other NSAIDs
• Pregnancy, labor, delivery, and nursing 4
• Cerebrovascular hemorrhage 2

High-Risk Populations

1. Elderly patients (≥65 years)

   • Require lower doses due to increased risk of adverse effects
   • Higher risk of GI bleeding and renal impairment 4

2. Patients with renal impairment

   • Ketorolac is primarily excreted through the kidneys
   • Elimination half-life increases with renal impairment 5, 6

3. Patients on anticoagulants

   • Increased risk of bleeding complications due to platelet inhibition 4

4. Patients with history of GI issues

   • Higher risk of GI bleeding, ulceration, and perforation 4

Monitoring Requirements

For patients receiving ketorolac, especially those at higher risk:

• Monitor blood pressure, BUN, creatinine, and liver function tests at baseline
• Continue monitoring every 3 months for long-term users (though long-term use is not recommended) 6
• Discontinue immediately if:
  • BUN or creatinine doubles
  • Hypertension develops or worsens
  • Signs of GI bleeding occur 6

Alternative Pain Management Options

When ketorolac is contraindicated or the 5-day maximum has been reached:

• For mild to moderate pain: Acetaminophen or other oral NSAIDs with appropriate precautions
• For moderate to severe pain: Transition to appropriate opioid analgesics 6
• For patients with renal impairment: Consider methadone as it has primarily fecal excretion rather than renal elimination 6

Key Takeaways

1. Ketorolac is a potent NSAID with significant analgesic properties but carries substantial risks
2. The 5-day maximum duration is an absolute limit that should never be exceeded
3. Patients should be transitioned to alternative analgesics as soon as possible
4. The lowest effective dose should always be used
5. Careful patient selection is essential to minimize adverse effects

Remember that while ketorolac is effective for short-term pain management, its use must be strictly limited due to its potential for serious adverse effects, particularly with prolonged use beyond the 5-day maximum.