Timing of Ketorolac (Toradol) Discontinuation Before Surgery
Ketorolac (Toradol) should be discontinued at least 24 hours before surgery to minimize the risk of perioperative bleeding complications. 1
Rationale for Discontinuation Timing
Ketorolac is a non-steroidal anti-inflammatory drug (NSAID) with strong analgesic properties that affects platelet aggregation and can increase the risk of surgical bleeding. The timing of discontinuation is based on several factors:
- Pharmacokinetic profile: Ketorolac has a half-life of approximately 4-6 hours 2, but its effects on platelet function can persist longer
- Bleeding risk: NSAIDs impair platelet function and can increase surgical bleeding
- FDA labeling: The FDA label for ketorolac emphasizes its hemorrhagic risk, noting that "prostaglandins play an important role in hemostasis and NSAIDs affect platelet aggregation" 3
Specific Recommendations Based on Surgery Type
Low Bleeding Risk Procedures
- Stop ketorolac at least 24 hours before surgery 1
- Examples: dental extractions, cataract surgery, endoscopy without biopsy
High Bleeding Risk Procedures
- Stop ketorolac at least 24 hours before surgery, but consider 48 hours for higher-risk procedures 1
- Examples: neurosurgery, cardiac surgery, major orthopedic procedures
Special Considerations
Renal Function
- For patients with renal impairment, consider stopping ketorolac earlier (36-48 hours before surgery) as elimination half-life increases in these patients 3, 2
- Ketorolac is contraindicated in patients with advanced renal impairment 3
Concomitant Medications
- Anticoagulants: Patients on therapeutic doses of anticoagulants have an increased risk of bleeding complications if given ketorolac concurrently 3
- Antiplatelet agents: Combined use with aspirin or other antiplatelet medications significantly increases bleeding risk 3
Age Considerations
- For elderly patients (≥65 years), consider stopping ketorolac 36 hours before surgery due to potentially prolonged elimination 3, 2
Postoperative Resumption
- Resume ketorolac 24-48 hours after surgery once adequate hemostasis is achieved and renal function is stable 4
- The FDA label specifies that the total combined duration of use of ketorolac tablets and IV/IM dosing should not exceed 5 days in adults 3
Common Pitfalls to Avoid
- Inadequate discontinuation time: Failing to stop ketorolac at least 24 hours before surgery increases bleeding risk
- Overlooking renal function: Not accounting for decreased clearance in patients with renal impairment
- Resuming too early: Restarting ketorolac too soon after surgery before adequate hemostasis is achieved
- Extended use: Using ketorolac for more than 5 days total (including pre and post-operative use) increases GI and renal toxicity risk 3
By adhering to these guidelines for ketorolac discontinuation before surgery, you can minimize the risk of perioperative bleeding complications while effectively managing pain.