Is IV Toradol (ketorolac) safe for someone with a gastrointestinal (GI) ulcer?

IV Toradol is Contraindicated in Patients with GI Ulcers

IV Toradol (ketorolac) is absolutely contraindicated in patients with active peptic ulcer disease, recent gastrointestinal bleeding or perforation, and in patients with a history of peptic ulcer disease or gastrointestinal bleeding. 1

Contraindication Evidence

The FDA label for ketorolac explicitly states that it is contraindicated in:

• Patients with active peptic ulcer disease
• Patients with recent gastrointestinal bleeding or perforation
• Patients with a history of peptic ulcer disease or gastrointestinal bleeding 1

This contraindication is not optional or situational - it is absolute. The FDA boxed warning emphasizes that ketorolac can cause:

• Peptic ulcers
• Gastrointestinal bleeding
• Perforation of the stomach or intestines
• These events can be fatal and can occur at any time during use without warning symptoms 1

Risks and Mechanisms

Ketorolac, like other NSAIDs, inhibits prostaglandin synthesis which:

• Reduces the protective mechanisms of the gastric mucosa
• Increases gastric acid secretion
• Impairs platelet function, increasing bleeding risk 2

Studies have shown that ketorolac has particularly high gastrotoxicity:

• A case-control study found ketorolac had a rate ratio of 5.9 for gastrointestinal hemorrhage or perforation 3
• Case reports document gastric ulcer perforation occurring after just 4 days of ketorolac treatment 4
• Another study found ketorolac had an adjusted relative risk of 9.8 for ulcers 5

Alternative Approaches

For patients with GI ulcers requiring pain management:

1. First-line alternatives:

   • Non-NSAID analgesics (acetaminophen/paracetamol) 2
   • For inflammatory conditions requiring short-term therapy, consider corticosteroids (steroids alone do not increase ulcer risk) 2

2. If stronger analgesia is needed:

   • Consider opioid analgesics with appropriate monitoring
   • Avoid combining with other NSAIDs or aspirin 1

Risk Reduction Strategies (for other NSAIDs, NOT for ketorolac with active ulcers)

For patients without active ulcers but with risk factors who require NSAIDs:

1. Use the least ulcerogenic NSAID at the lowest effective dose 6
2. Add gastroprotection:
   • Proton pump inhibitors (PPIs) reduce endoscopic NSAID-related ulcers by up to 90% 2, 7
   • Misoprostol reduces gastric ulcer risk by 74% and duodenal ulcer risk by 53% 2

Common Pitfalls

1. Ignoring the contraindication: The most dangerous pitfall is disregarding the absolute contraindication of ketorolac in patients with ulcers.

2. Short-term false security: Even short-term therapy with ketorolac is not without risk. The FDA warns that serious adverse events can occur at any time, with or without warning symptoms 1.

3. Relying on gastroprotection: Adding a PPI or misoprostol does NOT make ketorolac safe for patients with active ulcers - the contraindication remains absolute 1.

4. Overlooking H. pylori status: H. pylori infection increases the risk of NSAID-related ulcer complications by 2-4 fold; testing and eradication should be considered in patients requiring NSAIDs 2.

In conclusion, IV Toradol should never be administered to patients with active GI ulcers due to the high risk of life-threatening complications.