What is the gastrointestinal risk of intramuscular Toradol (Ketorolac)?

Gastrointestinal Risk of Intramuscular Toradol (Ketorolac)

Intramuscular ketorolac (Toradol) carries a significant risk of serious gastrointestinal complications including bleeding, ulceration, and perforation, even with short-term use. 1

Mechanism and Risk Profile

Ketorolac is a potent nonsteroidal anti-inflammatory drug (NSAID) with strong analgesic properties that can be administered intramuscularly. Despite its parenteral administration, it still poses substantial gastrointestinal risks:

• Ketorolac can cause serious GI adverse events including bleeding, ulceration, and perforation of the stomach, small intestine, or large intestine, which can be fatal 1
• These serious adverse events can occur at any time, with or without warning symptoms 1
• Only one in five patients who develop a serious upper GI adverse event on NSAID therapy is symptomatic 1
• The FDA label specifically warns that ketorolac is contraindicated in patients with previously documented peptic ulcers and/or GI bleeding 1

Risk Factors for GI Complications

The risk of GI complications with ketorolac increases with:

• History of peptic ulcer disease
• Concomitant use of oral corticosteroids or anticoagulants
• Longer duration of therapy (though limited to 5 days maximum)
• Smoking and alcohol use
• Older age (≥65 years)
• Poor general health status 1

Case Reports of GI Complications

Several case reports document serious GI complications with intramuscular ketorolac:

• A 39-year-old woman developed a perforated gastric ulcer after receiving multiple doses of intramuscular ketorolac over 2.5 months 2
• An 88-year-old woman developed a perforated prepyloric gastric ulcer after receiving 16 doses of ketorolac 30 mg IM 3
• An 80-year-old woman with no prior GI problems developed a prepyloric gastric ulcer that perforated after receiving 13 doses of ketorolac 30 mg IM 3
• An 85-year-old man with a history of gastric ulcer developed GI bleeding after receiving 9 doses of ketorolac 30 mg IM 3

Recommendations for Clinical Practice

1. Duration limitations: Do not use ketorolac for more than five days, as the incidence and severity of GI complications increase with longer treatment 1

2. Contraindications: Avoid ketorolac in patients with:

   • Previously documented peptic ulcers
   • History of GI bleeding
   • Inflammatory bowel disease (may be exacerbated)
   • Concomitant use of other NSAIDs or aspirin (increases cumulative risk) 1

3. Special populations: Use with extra caution in:

   • Elderly patients (require dose adjustment)
   • Patients under 50 kg (require dose adjustment)
   • Patients with moderately elevated serum creatinine 1

4. Monitoring: Remain alert for signs and symptoms of GI ulceration and bleeding during therapy and promptly evaluate if suspected 1

5. Risk minimization: Use the lowest effective dose for the shortest possible duration 1

Alternative Approaches

For patients at high risk of GI complications, consider:

• Alternative analgesics that don't involve NSAIDs 1
• Opioid analgesics may be safer alternatives for patients with high GI risk 4
• If ketorolac must be used in high-risk patients, consider prophylactic therapy with misoprostol 3

The evidence clearly demonstrates that even short-term intramuscular ketorolac therapy carries significant gastrointestinal risks, particularly in elderly patients and those with a history of GI problems.