Can you take ketorolac (Toradol) injection while on Xarelto (rivaroxaban)?

Concomitant Use of Ketorolac and Rivaroxaban

Ketorolac injection should not be administered to patients taking rivaroxaban (Xarelto) due to the significantly increased risk of bleeding complications.

Rationale for Contraindication

Ketorolac and rivaroxaban both affect hemostasis through different mechanisms, creating a dangerous combination:

1. Mechanism of interaction:

   • Ketorolac is a potent NSAID that inhibits platelet aggregation and prolongs bleeding time 1
   • Rivaroxaban is a direct factor Xa inhibitor that prevents thrombin formation and clot development
   • Combined use creates additive anticoagulant effects, substantially increasing bleeding risk

2. Evidence of risk:

   • Studies show ketorolac significantly prolongs bleeding time and inhibits platelet aggregation and thromboxane production 2
   • Even when used alone, ketorolac carries warnings about bleeding risk, especially with compromised hemostasis 1
   • The combination with anticoagulants creates a dangerous potentiation of bleeding risk

Clinical Guidelines and Recommendations

Guidelines provide clear direction against this combination:

• The Clinical Practice Guideline for Epistaxis notes that nonsteroidal anti-inflammatory drugs like ketorolac increase bleeding risk in patients on anticoagulants 3
• Patients taking anticoagulants who also receive NSAIDs are more likely to present with recurrent bleeding, large volume blood loss, and require blood transfusions 3
• The Chest Guidelines for Antithrombotic Therapy highlight that rivaroxaban's bleeding risk increases significantly when combined with medications affecting hemostasis 3

Alternative Approaches

For patients requiring pain management while on rivaroxaban:

• Consider acetaminophen as a first-line alternative for pain control
• If stronger analgesia is needed, consider reduced doses of opioid medications
• For inflammatory conditions, consider local treatments (injections of corticosteroids) rather than systemic NSAIDs
• If NSAID therapy is absolutely necessary, temporary interruption of rivaroxaban may be considered in consultation with the prescribing physician, weighing thrombotic vs. bleeding risks

High-Risk Scenarios

The risk is particularly elevated in:

• Elderly patients
• Patients with renal impairment
• Those with a history of GI bleeding
• Patients on multiple medications affecting hemostasis
• Recent or upcoming surgical procedures

Monitoring if Combination Cannot Be Avoided

If, in rare circumstances, this combination must be used (though strongly discouraged):

• Use the lowest effective dose of ketorolac for the shortest possible duration (absolute maximum 5 days)
• Monitor closely for signs of bleeding (bruising, petechiae, melena, hematuria)
• Consider laboratory monitoring of hemostatic parameters
• Educate the patient about bleeding signs and when to seek immediate medical attention

The evidence clearly demonstrates that the risks of combining ketorolac with rivaroxaban outweigh potential benefits in nearly all clinical scenarios, and alternative pain management strategies should be employed.