Is it safe to administer a one-time dose of Toradol (ketorolac) to a patient taking low-dose aspirin (acetylsalicylic acid)?

Safety of One-Time Toradol Dose in Patients Taking Low-Dose Aspirin

A one-time dose of Toradol (ketorolac) is not recommended for patients taking low-dose aspirin due to increased risk of gastrointestinal bleeding and other adverse effects. 1, 2

Mechanism of Concern

• Both ketorolac and aspirin are non-steroidal anti-inflammatory drugs (NSAIDs) that inhibit cyclooxygenase enzymes, leading to additive antiplatelet effects and increased bleeding risk 2
• The FDA drug label for ketorolac specifically mentions that "when ketorolac tromethamine is administered with aspirin, its protein binding is reduced" and "concomitant administration of ketorolac tromethamine and aspirin is not generally recommended because of the potential of increased adverse effects" 2
• The effects of NSAIDs and aspirin on gastrointestinal bleeding are synergistic, creating a higher risk than either drug alone 2

Specific Risks

• Increased risk of gastrointestinal bleeding, which is already elevated with low-dose aspirin therapy alone 3
• Potential for altered hemostasis and prolonged bleeding time 4
• Possible renal impairment, especially in patients with pre-existing kidney disease 2, 4
• Cardiovascular complications including worsened hypertension 1

Clinical Guidelines on NSAID Use

• The American Heart Association guidelines specifically state that "use of nonaspirin nonsteroidal anti-inflammatory drugs should be avoided for management of suspected or known ischemia pain whenever possible" 1
• NSAIDs are associated with increased risk of major adverse cardiovascular events in patients with and without prior cardiac disease 1
• The American Family Physician guidelines list "aspirin/NSAID-induced asthma" as a contraindication to ketorolac use 1
• The European Society of Cardiology notes that when NSAIDs must be used in patients on low-dose aspirin, physicians "should not discontinue treatment with low-dose aspirin, even though concomitant administration of the two may amplify the risk of upper GI bleeding" 1

Alternative Approaches

• Consider acetaminophen (paracetamol) as an alternative analgesic, which does not have antiplatelet effects 1
• If pain control is inadequate with acetaminophen alone, consider short-acting opioids with appropriate monitoring 1
• For patients requiring anti-inflammatory effects, consult with the prescribing physician about temporarily holding the aspirin (if clinically appropriate) before administering ketorolac 1

Special Considerations

• The risk is particularly high in elderly patients, those with a history of peptic ulcer disease, or patients taking other medications that affect coagulation 4
• If ketorolac must be used despite aspirin therapy (which is generally not recommended), it should be at the lowest effective dose for the shortest possible duration (not exceeding 5 days) 4
• Proton pump inhibitors may provide some protection against upper GI bleeding if combination therapy cannot be avoided 1, 3

Conclusion

Based on the available evidence and clinical guidelines, the combination of ketorolac and low-dose aspirin, even for a one-time dose, carries significant risks that outweigh potential benefits in most clinical scenarios 1, 2, 4. Alternative pain management strategies should be considered.