Is there a risk of bleeding with Toradol (Ketorolac)?

From the Guidelines

Yes, there is a significant risk of bleeding with Toradol (ketorolac), particularly in patients with a history of gastrointestinal bleeding, peptic ulcer disease, or those taking blood thinners like warfarin, heparin, or other anticoagulants. Toradol is a potent non-steroidal anti-inflammatory drug (NSAID) that can increase bleeding risk by inhibiting platelet aggregation and blood clotting. According to a study published in the Journal of the American College of Cardiology 1, the combined use of clopidogrel and nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin, has been associated with impaired healing of asymptomatic ulcers and with an increase in serious upper GI bleeding.

The bleeding risk increases with higher doses and longer duration of use, which is why Toradol is typically limited to short-term use (5 days or less) and specific dosing guidelines (typically 10mg orally every 4-6 hours, not exceeding 40mg daily, or 30mg IV/IM initially, followed by 15-30mg every 6 hours as needed). Elderly patients, those with kidney problems, or individuals with bleeding disorders face higher risks. A study published in Clinical Gastroenterology and Hepatology 1 found that NSAID use increases the risk for death, with a yearly mortality rate from NSAID use of 16,500 in the United States.

Key factors that increase the risk of bleeding with Toradol include:

• History of gastrointestinal bleeding or peptic ulcer disease
• Use of blood thinners like warfarin, heparin, or other anticoagulants
• Higher doses and longer duration of use
• Elderly patients
• Patients with kidney problems or bleeding disorders
• Concomitant use of corticosteroids, anticoagulants, or other NSAIDs

If you experience symptoms like black or bloody stools, vomiting blood, or unusual bruising while taking Toradol, seek immediate medical attention as these could indicate serious bleeding complications. Proton pump inhibitors (PPIs) may be used to decrease the risk of gastroduodenal ulcers and upper GI bleeding in patients taking aspirin or NSAIDs, including Toradol 1. However, the use of PPIs with clopidogrel may be associated with an increased risk of death or repeat hospital stay for acute coronary syndrome, and further investigation is needed to provide clarity around this issue.

From the FDA Drug Label

The most serious risks associated with ketorolac tromethamine are: Gastrointestinal Effects – Risk of Ulceration, Bleeding, and Perforation Ketorolac tromethamine can cause serious gastrointestinal (GI) adverse events including bleeding, ulceration and perforation, of the stomach, small intestine, or large intestine, which can be fatal. Hemorrhage Because prostaglandins play an important role in hemostasis and NSAIDs affect platelet aggregation as well, use of ketorolac tromethamine in patients who have coagulation disorders should be undertaken very cautiously, and those patients should be carefully monitored. Patients on therapeutic doses of anticoagulants (e.g., heparin or dicumarol derivatives) have an increased risk of bleeding complications if given ketorolac tromethamine concurrently; therefore, physicians should administer such concomitant therapy only extremely cautiously

Yes, there is a risk of bleeding with Toradol (Ketorolac) 2.

• The risk of bleeding is associated with the use of ketorolac tromethamine, particularly in patients with a history of peptic ulcers and/or GI bleeding.
• Patients on therapeutic doses of anticoagulants have an increased risk of bleeding complications if given ketorolac tromethamine concurrently.
• The concurrent use of ketorolac tromethamine and therapy that affects hemostasis may also be associated with an increased risk of bleeding 2.
• Ketorolac tromethamine, like other NSAIDs, can cause GI discomfort and rarely, serious GI side effects, such as ulcers and bleeding, which may result in hospitalization and even death 2.

From the Research

Risk of Bleeding with Toradol (Ketorolac)

• The use of Toradol (Ketorolac) has been associated with an increased risk of bleeding in some studies 3, 4.
• A study published in the British journal of plastic surgery found that ketorolac tromethamine (Toradol) strongly inhibits platelet aggregation, leading to prolonged bleeding times and reduced platelet aggregation 3.
• Another study published in The Laryngoscope found that perioperative ketorolac increases post-tonsillectomy hemorrhage in adults but not children 4.
• However, other studies have found that the risk of bleeding with Toradol is not significantly increased 5, 6.
• A meta-analysis of randomized controlled trials found that postoperative bleeding was not significantly increased with ketorolac compared with controls 6.
• A study published in Plastic and reconstructive surgery found that the incidence of postoperative hematomas in patients who received ketorolac was not significantly higher than in those who did not receive ketorolac 5.

Factors Influencing the Risk of Bleeding

• The risk of bleeding with Toradol may be influenced by factors such as age, with older patients being at higher risk 7.
• The dose of Toradol may also influence the risk of bleeding, with higher doses being associated with a greater risk 7.
• The type of surgery being performed may also influence the risk of bleeding, with surgeries involving considerable dissection of tissues being at higher risk 7.

Clinical Implications

• The use of Toradol should be carefully considered in patients who are at high risk of bleeding, such as those with a history of bleeding disorders or those taking anticoagulant medications 3, 7.
• The benefits of using Toradol for postoperative pain control should be weighed against the potential risks of bleeding 5, 6.
• Further studies are needed to fully understand the risks and benefits of using Toradol in different clinical settings 4, 6.