Is Toradol (ketorolac) better than Motrin (ibuprofen) for a patient with a gastrointestinal (GI) ulcer?

Neither Toradol nor Motrin Should Be Used in Patients with GI Ulcers

Both Toradol (ketorolac) and Motrin (ibuprofen) are contraindicated in patients with active gastrointestinal ulcers, and neither should be used as they can worsen the condition and lead to potentially life-threatening complications. 1, 2

Risk Assessment and NSAID Selection

NSAIDs, including both ketorolac and ibuprofen, increase the risk of GI complications through several mechanisms:

• Direct mucosal injury
• Inhibition of protective prostaglandins
• Exacerbation of underlying ulcer disease
• Potential worsening of H. pylori gastritis 3

For patients with existing GI ulcers:

• Active GI bleeding is an absolute contraindication to NSAID use 2
• A history of ulcer complications is the strongest risk factor for NSAID-related GI complications 1
• Patients with prior ulcer complications are considered "very high risk" and should avoid all NSAIDs if possible 1

Comparative Risk of Ketorolac vs. Ibuprofen

When comparing these two medications specifically:

1. Ketorolac (Toradol):

   • Multiple case reports document gastric ulcer perforations with injectable ketorolac, even with short-term use 4, 5, 6
   • Can cause both upper and lower GI tract ulceration through systemic effects 7
   • Has been associated with serious GI complications in elderly patients after just a few doses 5

2. Ibuprofen (Motrin):

   • Generally considered to have lower ulcerogenic potential at analgesic doses compared to other NSAIDs 1
   • However, at full anti-inflammatory doses (2.4g/day), the risk of GI bleeding becomes comparable to other NSAIDs 1
   • Still contraindicated in patients with active ulcers

Alternative Pain Management Strategies

For patients with GI ulcers requiring pain management:

1. First-line options:

   • Non-NSAID analgesics (acetaminophen/paracetamol) 1
   • For inflammatory conditions requiring short-term therapy, consider corticosteroids, as steroids alone do not increase ulcer risk 1

2. If analgesic therapy is absolutely necessary:

   • Consider COX-2 selective inhibitors with PPI co-therapy, though this approach is still not completely safe for patients with prior ulcer complications 1, 2
   • The combination of a COX-2 inhibitor and misoprostol may offer the best GI protection, though this remains to be fully evaluated in prospective trials 1

Important Considerations

• H. pylori infection increases the risk of NSAID-related ulcer complications by 2-4 fold; testing and eradication should be considered 1
• For patients with prior ulcer complications, neither co-therapy with anti-ulcer drugs nor substitution of a COX-2 inhibitor alone is a safe strategy 1
• Poor compliance with gastroprotective agents increases the risk of NSAID-induced adverse events 4-6 times 1

In conclusion, neither Toradol nor Motrin is appropriate for patients with GI ulcers. The focus should be on alternative pain management strategies and treating the underlying ulcer condition.