What is the initial dose of Toradol (ketorolac) for pain management?

Initial Dosing of Toradol (Ketorolac) for Pain Management

The initial dose of Toradol (ketorolac) for pain management is 30 mg intravenously (IV) or intramuscularly (IM) for most adults, with subsequent doses of 15 mg IV/IM every 6 hours as needed, not to exceed a maximum daily dose of 120 mg or duration of 5 days.

Dosing Guidelines by Route of Administration

Intravenous/Intramuscular Administration

• Initial dose: 30 mg IV/IM
• Maintenance dose: 15 mg IV/IM every 6 hours
• Maximum daily dose: 120 mg
• Maximum duration: 5 days 1

Oral Administration

• Not recommended as initial therapy
• Should follow parenteral administration
• Oral dosing: 10 mg every 4-6 hours
• Maximum daily oral dose: 40 mg

Dose Adjustments for Special Populations

Elderly Patients (≥65 years)

• Reduced dosing recommended due to higher risk of adverse effects 1
• Initial dose: 15 mg IV/IM
• Maximum daily dose: 60 mg

Low Body Weight Patients (<50 kg)

• Dose reduction required 1
• Initial dose: 15 mg IV/IM
• Maximum daily dose: 60 mg

Renal Impairment

• Use with caution or avoid in patients with advanced renal impairment 1
• Contraindicated in patients at risk of renal failure

Clinical Considerations

Efficacy

• Research demonstrates that ketorolac has similar analgesic efficacy at IV doses of 10,15, and 30 mg, suggesting that 10 mg may be the analgesic ceiling dose 2
• Despite this evidence, clinical practice patterns show that ketorolac is prescribed above its ceiling dose of 10 mg in 97% of patients receiving IV doses 3
• When used postoperatively with patient-controlled analgesia (PCA), ketorolac reduces morphine requirements by approximately 26% 4, 5

Duration of Therapy

• Maximum recommended duration is 5 days 1, 6
• Longer duration increases risk of adverse effects

Contraindications and Precautions

Absolute Contraindications

• History of peptic ulcer disease
• GI bleeding or perforation
• Advanced renal impairment
• Cerebrovascular bleeding
• Coagulation disorders
• Concurrent use with aspirin or other NSAIDs 1

Monitoring Requirements

• Baseline blood pressure
• Renal function tests (BUN, creatinine)
• Liver function tests
• Complete blood count
• Coagulation profile 1

Adverse Effects to Monitor

• GI upset, bleeding, and perforation (risk increases with higher doses and longer duration)
• Acute renal failure (usually reversible upon discontinuation)
• Inhibition of platelet aggregation and increased bleeding time
• Potential additive nephrotoxicity in patients receiving chemotherapy 1

Key Clinical Pearls

• Intramuscular injections are not recommended in children unless IV route is unavailable 7
• Ketorolac should not be used prophylactically for anticipated pain 6
• The lowest effective therapeutic dose should be used 6
• Consider as part of multimodal analgesia, particularly beneficial in pain resulting from bone metastases 1

Remember that while higher doses are commonly used in clinical practice, research suggests that the analgesic ceiling dose may be as low as 10 mg IV, with no additional pain relief but potentially increased risk of adverse effects at higher doses 2.