Is 15mg intramuscular (IM) Toradol (ketorolac) safe to administer to a patient with a history of gastric varices, peptic ulcer disease, and a previous perforated viscus with laparoscopic repair?

Ketorolac (Toradol) Is Contraindicated in Patients with History of Gastric Varices and Peptic Ulcer Disease with Perforation

Intramuscular ketorolac (15mg) is absolutely contraindicated in this patient with a history of gastric varices and perforated peptic ulcer disease due to the significantly increased risk of gastrointestinal bleeding and perforation.

Contraindications for Ketorolac in This Patient

• Ketorolac is explicitly contraindicated in patients with active peptic ulcer disease, recent gastrointestinal bleeding or perforation, and in patients with a history of peptic ulcer disease or gastrointestinal bleeding 1
• The FDA label specifically warns that 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
• Patients with a history of peptic ulcer disease with perforation are at significantly higher risk for recurrent perforation when exposed to NSAIDs like ketorolac 1
• Gastric varices that were previously glued represent a significant risk factor for bleeding, especially when exposed to medications that affect platelet function and hemostasis 1

Mechanism of Risk

• Ketorolac inhibits platelet function and is therefore contraindicated in patients with incomplete hemostasis and those at high risk of bleeding 1
• Even short-term therapy with ketorolac is not without risk, as serious GI adverse events can occur at any time, with or without warning symptoms 1
• Only one in five patients who develop serious upper GI adverse events on NSAID therapy is symptomatic, making monitoring for complications difficult 1
• The risk of GI complications increases with increasing dose and duration of treatment with ketorolac 1

Alternative Pain Management Options

• For this high-risk patient, alternative non-NSAID analgesics should be considered 1
• Tramadol is not a suitable alternative as it has been associated with increased mortality in patients with perforated peptic ulcers (adjusted 30-day mortality rate ratio of 2.02 compared to patients using neither tramadol nor NSAIDs) 2
• Acetaminophen or opioid analgesics would be safer alternatives for pain management in this patient 3
• If pain control is inadequate with these alternatives, consultation with pain management specialists may be warranted 3

Clinical Considerations for Patients with History of Perforated Peptic Ulcer

• Peptic ulcer perforation is a life-threatening surgical emergency with mortality rates of up to 30% 4
• The primary management approach for perforated peptic ulcers is surgery, though conservative management can be conducted in highly selected cases 5
• Laparoscopic repair is the preferred surgical approach for perforated peptic ulcers when needed 6
• Patients with a history of peptic ulcer perforation should be monitored for Helicobacter pylori infection and treated if positive 4

Important Monitoring Considerations

• If any analgesic is given to this high-risk patient, close monitoring for signs of GI bleeding is essential 1
• Patients and physicians should remain alert for signs and symptoms of GI ulceration and bleeding during any pain management therapy 1
• Prompt discontinuation of any potentially harmful medication and immediate evaluation is necessary if a serious GI adverse event is suspected 1

In conclusion, the patient's history of gastric varices and perforated peptic ulcer disease represents absolute contraindications to the use of ketorolac, even at a reduced dose of 15mg IM. The risk of potentially fatal gastrointestinal bleeding or recurrent perforation far outweighs any analgesic benefit.