Can I administer Ketorolac (Toradol) to a patient on Apixaban (Eliquis)?

From the Guidelines

I strongly advise against administering Ketorolac (Toradol) to a patient on Apixaban (Eliquis) due to the significantly increased risk of bleeding complications.

Reasoning

The combination of these two medications affects blood clotting through different mechanisms, creating a dangerous additive effect on bleeding risk. Apixaban is an anticoagulant that directly inhibits factor Xa in the clotting cascade, while Ketorolac is a non-steroidal anti-inflammatory drug (NSAID) that inhibits platelet aggregation and can cause gastric irritation and ulceration 1.

Alternatives for Pain Management

For pain management in patients on Eliquis, safer alternatives include:

• Acetaminophen (Tylenol) up to 3000mg daily in divided doses
• In cases of more severe pain, consultation with the prescribing physician about short-term, low-dose opioid options If the patient absolutely requires an anti-inflammatory medication, the prescribing physician should carefully weigh the risks versus benefits and potentially consider temporarily adjusting the Eliquis dosage while closely monitoring for bleeding signs 1.

Clinical Considerations

It is crucial to consider the patient's overall clinical context, including their renal function, as both medications can affect kidney function and increase the risk of bleeding complications. The 2018 European Heart Rhythm Association practical guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation provides valuable insights into the management of patients on Apixaban, emphasizing the importance of monitoring renal function and adjusting the dose accordingly 1.

Key Takeaway

The risk of bleeding complications associated with the combination of Ketorolac and Apixaban outweighs any potential benefits, and alternative pain management strategies should be prioritized to ensure patient safety.

From the Research

Administration of Ketorolac with Apixaban

• The provided studies do not directly address the administration of Ketorolac (Toradol) to a patient on Apixaban (Eliquis) 2, 3, 4, 5, 6.
• However, it is known that Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) with antiplatelet effects, which may increase the risk of bleeding when combined with anticoagulants like Apixaban 5.
• A study on the association of oral anticoagulants and proton pump inhibitor cotherapy with hospitalization for upper gastrointestinal tract bleeding found that Apixaban had a lower incidence of hospitalization for upper gastrointestinal tract bleeding compared to other anticoagulants 2.
• Another study discussed the use of anticoagulants in patients with chronic renal impairment, but did not provide specific information on the combination of Ketorolac and Apixaban 3.
• A review of drug-drug interactions associated with proton pump inhibitors mentioned that clinicians should be vigilant for interactions that may be clinically significant and require dose adjustment or therapeutic monitoring, but did not address the specific combination of Ketorolac and Apixaban 4.
• A study on the use of vitamin K in patients on anticoagulant therapy provided guidance on the management of over-anticoagulation, but did not address the use of Ketorolac with Apixaban 6.

Key Considerations

• The potential increased risk of bleeding when combining Ketorolac with Apixaban should be considered 5.
• The lack of direct evidence on the administration of Ketorolac with Apixaban highlights the need for careful evaluation of the patient's individual risk factors and medical history 2, 3, 4, 5, 6.