What is the risk of a one-time injection of Toradol (Ketorolac) in a patient with a history of cerebral vascular accident (CVA) 4 years ago with no residual symptoms?

Risk Assessment for One-Time Toradol Injection in a Patient with Prior CVA

A one-time injection of Toradol (ketorolac) is contraindicated in a patient with a history of cerebrovascular accident (CVA), even if it occurred 4 years ago with no residual symptoms, due to increased risk of cardiovascular thrombotic events.

Cardiovascular Risk Considerations

FDA Contraindications and Warnings

The FDA label for ketorolac clearly states significant cardiovascular risks:

• NSAIDs, including ketorolac, increase the risk of serious cardiovascular thrombotic events, including myocardial infarction and stroke, which can be fatal 1
• This increased risk applies to patients with or without known cardiovascular disease or risk factors, though those with existing cardiovascular disease have a higher absolute incidence of adverse events 1
• The increased risk of cardiovascular thrombotic events can begin as early as the first few weeks of treatment 1

Specific Concerns for Post-CVA Patients

Patients with a history of cerebrovascular events are at particularly high risk:

• The American Heart Association recommends avoiding vasodilating agents like ketorolac in patients with prior stroke or TIA due to increased risk of adverse events 2
• Observational studies have demonstrated that patients treated with NSAIDs in the post-MI period were at increased risk of reinfarction, CV-related death, and all-cause mortality 1
• While this data specifically references MI patients, the same cardiovascular risk principles apply to patients with cerebrovascular disease

Risk Stratification

The risk of a one-time Toradol injection in this patient must be evaluated in the context of:

1. Recurrent CVA risk: Patients with prior CVA have a baseline increased risk of recurrent cerebrovascular events
2. Medication interactions: If the patient is on antiplatelet or anticoagulant therapy for secondary stroke prevention, ketorolac significantly increases bleeding risk 3
3. Time since event: While 4 years have passed since the CVA, the patient remains at higher baseline risk than the general population

Alternative Pain Management Options

For patients with a history of CVA requiring pain management:

• Consider acetaminophen as a first-line alternative
• If stronger analgesia is needed, consider short-term opioid therapy under close supervision
• For inflammatory conditions, consider local steroid injections that have minimal systemic effects

Clinical Decision Algorithm

1. Identify contraindications: History of CVA is a contraindication to ketorolac use
2. Assess current antiplatelet/anticoagulant therapy: Concurrent use with ketorolac significantly increases bleeding risk
3. Consider alternative pain management options based on the specific indication for which Toradol was being considered

Conclusion

The risk-benefit analysis strongly favors avoiding even a one-time Toradol injection in a patient with prior CVA history. The cardiovascular risks outweigh the potential short-term analgesic benefits, regardless of the absence of residual symptoms and the time elapsed since the event.