What is the maximum number of days per month that intramuscular (IM) Ketorolac (generic name: Ketorolac tromethamine) can be safely used?

Maximum Safe Duration of Intramuscular Ketorolac Use

Intramuscular ketorolac (Toradol) should not be used for more than 5 consecutive days per month to ensure patient safety. 1

Dosing and Duration Guidelines

Ketorolac is a potent non-steroidal anti-inflammatory drug (NSAID) with strong analgesic properties used for short-term management of moderate to severe pain. The recommended dosing parameters are:

• Maximum daily dose: 120 mg per day 1
• Maximum duration: 5 consecutive days total 1
• Standard IM dosing: 60 mg initially, then 30 mg every 6 hours as needed 1
• Reduced dosing for high-risk patients: For elderly patients (≥65 years), those with renal impairment, or low body weight (<50 kg), doses should be reduced 1

Rationale for the 5-Day Limit

The 5-day duration limit is based on safety considerations:

• Increased adverse events with longer use: The risk of serious gastrointestinal bleeding and renal complications increases markedly when ketorolac is used at high doses for more than 5 days, especially in elderly patients 1
• FDA-approved labeling: The maximum duration of 5 days reflects the drug's FDA-approved labeling and is supported by clinical guidelines from the American Academy of Family Physicians 1

Risks of Exceeding Recommended Duration

Extending ketorolac use beyond 5 days significantly increases the risk of:

• Gastrointestinal bleeding and perforation
• Acute renal failure
• Platelet dysfunction and altered hemostasis
• Cardiovascular events, particularly in patients with underlying cardiovascular disease 1

Monitoring During Ketorolac Use

When administering intramuscular ketorolac, the following monitoring is recommended:

• Baseline assessment of blood pressure, BUN, creatinine, liver function tests, and CBC 1
• Regular assessment of renal function throughout treatment
• Immediate discontinuation if:
  • Renal function tests double
  • Hypertension develops or worsens
  • Liver function studies increase beyond normal limits 1

Alternative Pain Management Options

For patients requiring pain management beyond the 5-day limit:

• Transition to oral NSAIDs: Consider switching to oral ibuprofen (800 mg every 6 hours is approximately equivalent to 30 mg IV ketorolac every 6 hours) 1
• Acetaminophen: 1000 mg IV/PO can be used as an alternative 1
• Opioids: Small doses may be used for breakthrough pain when necessary 1

Key Contraindications

Ketorolac should be avoided 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
• Aspirin/NSAID-induced asthma 1

Following these guidelines ensures that intramuscular ketorolac is used safely and effectively while minimizing the risk of serious adverse events.