Is ketoralac (Toradol) safe during lactation?

Ketorolac Safety During Lactation

Ketorolac is safe to use during breastfeeding as it transfers minimally into breast milk with low levels detected and no reported adverse effects in nursing infants. 1, 2

Evidence on Ketorolac in Lactation

Ketorolac has been specifically identified as a safe option for breastfeeding women with pain, according to the Praxis Medical Insights summary of clinical guidelines 1. The FDA drug label provides supporting evidence, noting that after administration of 10 mg ketorolac tablets:

• Maximum milk concentration observed was only 7.3 ng/mL
• Maximum milk-to-plasma ratio was very low at 0.037
• With regular dosing (10 mg every 6 hours), maximum milk concentration remained low at 7.9 ng/mL
• Calculated maximum daily infant exposure was just 0.00263 mg/kg/day, which is only 0.4% of the maternal weight-adjusted dose 2

Clinical Considerations When Using Ketorolac

Dosing and Administration

• Use the lowest effective dose for the shortest duration possible
• Consider timing administration immediately after breastfeeding to maximize clearance time before the next feeding
• Standard adult dosing is appropriate with no special dosage adjustment needed for lactation 1

Special Populations

• Exercise extra caution with infants less than 6 weeks of age due to their immature hepatic and renal function
• Older infants (>6 months) have more mature metabolism and are at lower risk for adverse effects 1
• For geriatric patients who are breastfeeding, reduced dosages and careful monitoring are recommended due to potentially slower clearance 2

Alternative Pain Management Options

If concerned about using ketorolac, other safe options for breastfeeding mothers include:

1. First-line options:

   • Ibuprofen (minimal transfer to breast milk)
   • Paracetamol/acetaminophen (minimal transfer to breast milk) 1

2. Other safe NSAIDs:

   • Diclofenac
   • Naproxen
   • Celecoxib 1

3. Non-pharmacological approaches:

   • Exercise therapy
   • Yoga or tai chi
   • Massage therapy
   • Application of superficial heat
   • Acupuncture 1

Important Caveats

• Avoid aspirin at analgesic doses (though low-dose aspirin for anti-platelet action is acceptable)
• Avoid orphenadrine and diazepam due to lack of safety data or significant transfer to breast milk 1
• The Association of Anaesthetists guideline confirms that most medications used in anesthesia and sedation, including local anesthetics, are compatible with breastfeeding 3

Conclusion

The benefits of adequate pain control for maternal comfort and successful breastfeeding outweigh the minimal risk of ketorolac exposure through breast milk. The extremely low levels of ketorolac detected in breast milk (0.4% of maternal dose) make it a safe option for breastfeeding mothers requiring pain management.