What is the risk of gastrointestinal (GI) bleed with Toradol (Ketorolac) 30 mg intramuscularly (IM)?

Risk of GI Bleeding with Toradol 30 mg IM

Ketorolac (Toradol) 30 mg IM carries a significantly higher risk of gastrointestinal bleeding compared to other NSAIDs, with studies showing it to be approximately 5 times more gastrotoxic than other NSAIDs, even with short-term use.

Risk Assessment

Ketorolac is associated with substantial risk of GI complications, even when administered intramuscularly. The evidence shows:

• Ketorolac presents the highest risk among NSAIDs for GI bleeding with a relative risk of 24.7 compared to non-NSAID users 1
• It is approximately 5 times more gastrotoxic than all other NSAIDs (RR 5.5) 1
• The elevated risk is present even during the first week of therapy and with both oral and intramuscular administration 1

Risk Factors That Increase GI Bleeding Risk

Several factors significantly increase the risk of GI bleeding with ketorolac:

• Age ≥75 years: Elderly patients have a 66% higher risk of GI bleeding compared to younger patients 2
• History of peptic ulcer disease: This is the strongest risk factor for subsequent upper GI bleeding 3
• Dose-dependent risk: Higher daily doses correlate with increased bleeding risk 2
• Duration of therapy >5 days: Risk increases substantially when therapy extends beyond 5 days (OR 2.20) 2
• Concomitant medications: Use of anticoagulants, steroids, or other NSAIDs including aspirin 3
• H. pylori infection: Presence increases risk 3

Case Reports of Severe GI Complications

Multiple case reports document severe GI complications with ketorolac:

• An 88-year-old woman developed a perforated prepyloric gastric ulcer after receiving 16 doses of ketorolac 30 mg IM 4
• An 80-year-old woman with no prior GI history developed a perforated prepyloric gastric ulcer after 13 doses of ketorolac 30 mg IM 4
• An 85-year-old man with history of gastric ulcer developed GI bleeding after only 9 doses of ketorolac 30 mg IM 4
• A 77-year-old woman with no previous history of peptic ulcer disease developed a perforated gastric ulcer after just four days of treatment with ketorolac 5

Risk Mitigation Strategies

To minimize GI bleeding risk when using ketorolac:

1. Use lowest effective dose: Prescribe at the lowest dosage necessary to control pain 6
2. Limit duration: Restrict therapy to as few days as possible, ideally ≤5 days 6, 2
3. Consider gastroprotection: Add a proton pump inhibitor (PPI) for high-risk patients 3
4. Avoid in high-risk patients: Do not use in patients with history of gastric ulcer disease 4
5. Monitor closely: Watch for signs of GI bleeding, especially in elderly patients 6

Contraindications

Ketorolac should be avoided in patients with:

• History of or current risk of GI bleeding
• Risk of renal failure
• Compromised hemostasis
• Hypersensitivity to aspirin or other NSAIDs 6

Conclusion

When considering ketorolac 30 mg IM, clinicians should be aware of its significantly elevated risk profile for GI bleeding compared to other analgesics. The European Society of Cardiology Working Group on Cardiovascular Pharmacotherapy notes that NSAIDs increase risk of GI bleeding, with ketorolac being particularly high-risk 3. For patients requiring pain management, especially those with risk factors for GI bleeding, alternative analgesics should be strongly considered.