What are the guidelines for using Toradol (Ketorolac) oral for pain management?

Guidelines for Using Oral Ketorolac (Toradol) for Pain Management

Oral ketorolac should only be used as continuation therapy following IV/IM administration, with a maximum combined duration of 5 days, and is not approved as an initial treatment for pain management. 1

Dosage Recommendations

• For adults aged 17-64 years transitioning from IV/IM ketorolac: 20 mg PO once, followed by 10 mg every 4-6 hours as needed, not exceeding 40 mg/day 1
• For adults ≥65 years, renally impaired patients, and those weighing <50 kg: 10 mg PO once, followed by 10 mg every 4-6 hours as needed, not exceeding 40 mg/day 1
• Oral ketorolac is not approved for use in patients under 17 years of age 1
• Always use the lowest effective dose for the shortest duration consistent with individual patient treatment goals 1

Clinical Applications

• Oral ketorolac provides analgesia comparable to other commonly available oral analgesics, including ibuprofen and acetaminophen with codeine 2
• It can be used as an alternative to opioid therapy for short-term management of acute postoperative pain 3
• For moderate pain (pain intensity rating 4-6), NSAIDs like ketorolac can be considered as part of pain management strategy 4
• Oral ketorolac 20 mg has shown analgesic efficacy comparable to 5-10 mg of IM morphine in postoperative orthopedic pain 3

Administration Guidelines

• Oral ketorolac should never be given as an initial dose; it must follow IV or IM dosing of ketorolac 1
• The dosing interval should not be shortened below 4-6 hours 1
• Absorption is rapid with peak concentration reached between 20-60 minutes after oral administration 5
• Oral bioavailability ranges from 80-100% 5

Contraindications and Precautions

• Avoid in patients with:
  • Active peptic ulcer disease or GI bleeding 6
  • Aspirin/NSAID-induced asthma 6
  • Pregnancy 6
  • Cerebrovascular hemorrhage 6
  • Renal impairment (use with caution) 6
• Use with caution in:
  • Patients ≥60 years of age 6
  • Those with compromised fluid status 6
  • Patients with interstitial nephritis or papillary necrosis 6
  • Those on concomitant nephrotoxic drugs 6

Monitoring Recommendations

• Monitor baseline blood pressure, BUN, creatinine, liver function tests, CBC, and fecal occult blood 6
• For long-term therapy (though not recommended beyond 5 days), repeat these tests every 3 months 6
• Watch for common adverse effects including:
  • Edema 6
  • Drowsiness 6
  • Dizziness 6
  • Gastrointestinal upset 6
  • Increased diaphoresis 6

Special Considerations

• Elimination half-life is between 4-6 hours 5
• The elderly exhibit reduced clearance of the drug 5
• Ketorolac is extensively metabolized through glucuronidation and oxidation 5
• Most of the dose is recovered in urine as conjugated drug 5
• Ketorolac has a synergistic effect when combined with opioids, allowing for lower opioid doses and reduced opioid-related adverse effects 7

Important Limitations

• The combined duration of IV/IM and oral ketorolac must not exceed 5 days 1
• Oral ketorolac has limited utility as an initial treatment for moderate-to-severe acute pain 2
• For procedure-related pain (e.g., IUD placement), oral ketorolac 20 mg taken 40-60 minutes before the procedure may reduce pain during and after the procedure 4