Can you take Toradol (ketorolac) if you are taking Eliquis (apixaban)?

Concurrent Use of Toradol (Ketorolac) and Eliquis (Apixaban)

Toradol (ketorolac) should not be taken concurrently with Eliquis (apixaban) due to the significantly increased risk of bleeding complications.

Mechanism of Interaction

• Ketorolac is an NSAID that inhibits platelet aggregation and prolongs bleeding time through inhibition of prostaglandin synthesis 1
• Apixaban is a direct factor Xa inhibitor that prevents blood clotting by inhibiting the coagulation cascade 2
• The combination creates a synergistic anticoagulant effect that substantially increases bleeding risk beyond either medication alone 3

Bleeding Risk Assessment

• NSAIDs like ketorolac can cause gastrointestinal bleeding independently, which is further potentiated when combined with anticoagulants like apixaban 2
• Apixaban's FDA label specifically warns about increased bleeding risk when taken with NSAIDs 2
• The FDA label for ketorolac explicitly cautions about increased bleeding risk when combined with anticoagulants 3

Alternative Pain Management Options

• For patients on apixaban requiring pain management:
  • Acetaminophen is generally considered safer as it lacks antiplatelet effects 4
  • If stronger analgesia is needed, consider short-term opioid medications under close supervision 4
  • Non-pharmacological pain management strategies should be employed when possible 4

Special Considerations

• If ketorolac must be used in a patient on apixaban (which is strongly discouraged):
  • Consider temporary discontinuation of apixaban if the bleeding risk is acceptable based on thrombotic risk 5
  • Monitor closely for signs of bleeding including:
    • Unexpected bruising
    • Prolonged bleeding from cuts
    • Red, pink, or brown urine
    • Red or black stools
    • Nosebleeds or gum bleeding 2

Common Pitfalls to Avoid

• Assuming that short-term use of ketorolac with apixaban is safe - even brief concurrent use significantly increases bleeding risk 3
• Failing to recognize that the bleeding risk extends beyond the period of active administration due to the pharmacokinetic properties of both medications 2, 3
• Not considering that renal impairment can further increase bleeding risk by delaying clearance of both medications 5

Clinical Decision Algorithm

1. Determine if pain management is needed for a patient on apixaban
2. First-line: Use acetaminophen for mild to moderate pain 4
3. Second-line: Consider short-term opioid analgesics if acetaminophen is insufficient 4
4. Avoid NSAIDs, particularly ketorolac, due to high bleeding risk 2, 3
5. If surgical or procedural pain management is needed, consider regional anesthesia techniques that don't require systemic anticoagulant interruption 6