What is the recommended dosing frequency for intravenous (IV) ketorolac?

Intravenous Ketorolac Dosing Guidelines

Intravenous ketorolac should be administered every 6 hours, with a maximum duration of 5 days, as specified in the FDA label. 1

Standard Dosing Recommendations

For IV ketorolac administration:

• Adults <65 years of age:

  • 30 mg IV every 6 hours
  • Maximum daily dose: 120 mg 1

• High-risk populations (≥65 years, renally impaired, or <50 kg body weight):

  • 15 mg IV every 6 hours
  • Maximum daily dose: 60 mg 1

Administration Guidelines

• IV bolus must be given over no less than 15 seconds 1
• Onset of analgesic effect begins in approximately 30 minutes
• Maximum effect occurs in 1-2 hours after dosing
• Duration of analgesic effect is usually 4-6 hours 1

Important Considerations

1. Duration limitations:

   • Ketorolac therapy should not exceed 5 days total 1, 2
   • Patients should be switched to alternative analgesics as soon as possible 1

2. For breakthrough pain:

   • Do not increase the dose or frequency of ketorolac
   • Consider supplementing with low doses of opioids as needed unless contraindicated 1

3. Compatibility issues:

   • Ketorolac should not be mixed in a small volume (e.g., in a syringe) with morphine sulfate, meperidine hydrochloride, promethazine hydrochloride, or hydroxyzine hydrochloride as this will result in precipitation 1

Contraindications

Ketorolac is contraindicated in patients with:

• History of or current risk of gastrointestinal bleeding
• Risk of renal failure
• Compromised hemostasis
• Hypersensitivity to aspirin or other NSAIDs
• Pregnancy
• Cerebrovascular hemorrhage 2

Special Populations

For postoperative pain management after cesarean delivery, the American Journal of Obstetrics and Gynecology recommends:

• Ketorolac 30 mg IV every 6 hours for 24 hours, followed by ibuprofen 600 mg orally every 6 hours 3

Evidence on Efficacy and Safety

Research has demonstrated that ketorolac provides substantial pain relief for most patients with moderate to severe postoperative pain 4. A randomized controlled trial showed that lower doses (10 mg) of IV ketorolac provide similar analgesic efficacy to higher doses (15 mg and 30 mg) in emergency department patients with acute pain 5, suggesting that using the lowest effective dose may minimize potential adverse effects.

Adverse Effects

Common adverse effects include:

• Gastrointestinal bleeding and perforation
• Platelet inhibition with altered hemostasis
• Renal impairment 6

The risk for adverse events increases with:

• High doses
• Prolonged therapy (>5 days)
• Vulnerable patients (e.g., elderly) 6

In summary, IV ketorolac should be administered every 6 hours, with appropriate dose adjustments for high-risk populations, and treatment should not exceed 5 days. Careful patient selection and adherence to dosing guidelines are essential to minimize adverse effects while providing effective pain management.