Ketorolac Side Effects and Risk Profile
Ketorolac is a potent NSAID that carries significant risks of gastrointestinal bleeding, renal failure, and cardiovascular complications, and should be limited to short-term use (maximum 5 days) at the lowest effective dose with careful patient selection to minimize potentially fatal adverse events. 1
Major Side Effects and Risks
Gastrointestinal Effects
- GI bleeding and ulceration: Can occur without warning symptoms and may result in hospitalization or death
- Risk increases significantly with:
- Age >60 years
- History of peptic ulcer disease
- Alcohol use (≥2 drinks per day)
- High doses or prolonged use
- Concurrent use of glucocorticoids or anticoagulants 2
- Prevalence of dyspepsia and GI discomfort is 10-20% 2
- One-year risk of serious GI bleeding is 1 in 110 adults older than 75 years 2
Renal Effects
- Can cause acute renal failure, particularly in high-risk patients
- Risk factors include:
- Approximately 2% of patients stop taking NSAIDs due to renal complications 2
- Monitoring: Discontinue if BUN or creatinine doubles or if hypertension develops/worsens 2
Cardiovascular Effects
- Can cause or worsen hypertension
- Increases risk of myocardial infarction and stroke
- Avoid in patients with:
- Meta-analysis shows NSAIDs can increase blood pressure by an average of 5 mm Hg 2
Hematologic Effects
- Inhibits platelet aggregation and prolongs bleeding time
- Unlike aspirin, effect is quantitatively less, shorter in duration, and reversible
- Contraindicated in patients with:
- Coagulation disorders
- Thrombocytopenia
- Concurrent use of anticoagulants 1
- Risk of GI bleeding increases 3-6 times when used with anticoagulants 2
Hepatic Effects
- Can cause transaminitis and impaired synthetic function
- Avoid in patients with cirrhosis
- Monitor liver function tests periodically
- Discontinue if liver function tests increase above 3 times the upper limit of normal 2, 1
Respiratory Effects
- Can trigger bronchospasm in patients with aspirin-sensitive asthma
- Prevalence of aspirin-exacerbated respiratory disease is up to 21% in adults with asthma 2
- Contraindicated in patients with aspirin sensitivity 1
Risk Mitigation Strategies
Patient Selection
- Carefully screen for contraindications:
Dosing Considerations
- Use lowest effective dose for shortest duration possible
- Maximum duration: 5 days for adults
- Consider short-term use of ketorolac (15-30 mg IV) for maximum of 5 days 2, 3
Monitoring
- Baseline assessment:
- Blood pressure
- BUN, creatinine
- Liver function tests
- CBC and fecal occult blood 2
- Repeat every 3 months during long-term therapy (though long-term use is generally not recommended) 2
Alternatives
- If ketorolac is contraindicated, consider:
- Acetaminophen
- Selective COX-2 inhibitors (for patients at high risk of GI complications but low CV risk)
- Opioid analgesics (described as "safe and effective alternatives to NSAIDs") 2
Special Populations
Elderly Patients
Surgical Patients
- Use with caution in procedures involving considerable tissue dissection
- Risk of bleeding complications is only slightly higher than with opioids when used according to guidelines 4, 5
Cancer Patients
- May be beneficial for pain from bone metastases
- Use with caution in patients receiving chemotherapy, as NSAIDs can increase hematologic, renal, hepatic, and cardiovascular toxicities of chemotherapy 2, 4
Ketorolac remains a valuable analgesic option when used appropriately, but its potency comes with significant risks that must be carefully managed through proper patient selection, dosing, and monitoring.