Ketorolac Dosing in Elderly Patients
For elderly patients (≥65 years), ketorolac should be dosed at 10 mg IV/IM as a single dose, followed by 10 mg every 4-6 hours as needed, not exceeding 40 mg/day, with treatment duration limited to a maximum of 5 days. 1
FDA-Approved Dosing for Elderly
The FDA drug label explicitly mandates dose reduction for elderly patients:
- Initial dose: 10 mg PO once (following IV/IM ketorolac administration)
- Maintenance: 10 mg every 4-6 hours as needed
- Maximum daily dose: 40 mg/day
- Maximum treatment duration: 5 days (combined IV/IM and oral) 1
This reduced dosing applies to patients ≥65 years, those with renal impairment, and/or those weighing <50 kg (110 lbs). 1
Rationale for Dose Reduction
High-Risk Population Considerations
Elderly patients (≥60 years) are at significantly elevated risk for NSAID-related toxicities, including: 2
- Renal toxicity: Age-related decline in renal function, compromised fluid status, and increased risk of interstitial nephritis 2
- Gastrointestinal toxicity: History of peptic ulcer disease, increased risk of GI bleeding and perforation 2
- Cardiovascular toxicity: Higher risk of hypertension, acute decompensated heart failure, and cardiovascular complications 2
The 2019 American Geriatrics Society Beers Criteria specifically recommends avoiding nonselective NSAIDs in older adults with high risk of cerebrovascular accidents or heart failure. 2
Clinical Evidence Supporting Lower Doses
Analgesic Ceiling Effect
Ketorolac demonstrates an analgesic ceiling effect at 10 mg IV, meaning higher doses provide no additional pain relief while increasing toxicity risk:
- A randomized controlled trial comparing 10 mg, 15 mg, and 30 mg IV ketorolac showed equivalent pain reduction at 30 minutes across all three doses (mean NRS reduction of 2.6-3.0 points), with no statistical differences between groups. 3
- The 10 mg dose provided effective pain relief without increased adverse effects compared to higher doses. 3
Safety in Elderly Patients
Recent evidence supports the safety of appropriately dosed ketorolac in selected elderly patients:
- A retrospective study of 260 elderly ED patients receiving ketorolac 15 mg IV or 30 mg IM showed low rates of rescue analgesia (6.5%) and minimal adverse events. 4
- Single-dose parenteral ketorolac in geriatric ED patients (≥65 years) was not associated with increased cardiovascular, gastrointestinal, or renal adverse outcomes compared to matched controls. 5
Monitoring Requirements
For elderly patients receiving ketorolac, baseline and ongoing monitoring should include: 2
- Blood pressure (monitor for hypertension development or worsening)
- Renal function: BUN and creatinine (discontinue if creatinine doubles)
- Liver function studies: alkaline phosphatase, LDH, SGOT, SGPT
- CBC and fecal occult blood
- Repeat monitoring every 3 months if extended use is considered (though duration should not exceed 5 days)
Critical Contraindications in Elderly
Absolute contraindications include: 2
- Aspirin/NSAID-induced asthma
- Active peptic ulcer disease or GI bleeding
- Cerebrovascular hemorrhage
- Severe renal impairment (creatinine clearance <10 mL/min)
- Concurrent anticoagulant therapy (warfarin, heparin) due to bleeding risk 2
Common Pitfalls to Avoid
Do not use standard adult doses (30-60 mg) in elderly patients, as this practice was observed in 97% of IV administrations and 96% of IM administrations in one study, despite evidence of an analgesic ceiling at 10 mg. 6 This represents inappropriate prescribing that exposes elderly patients to unnecessary toxicity risk without additional benefit.
Do not exceed 5 days total duration of ketorolac therapy (combined parenteral and oral routes), as prolonged use significantly increases risk of serious adverse events including GI bleeding, renal failure, and cardiovascular complications. 1
Do not use ketorolac as monotherapy for severe pain; consider combination with opioids for synergistic effect and opioid-sparing benefits, which reduces opioid-related adverse effects while maintaining adequate analgesia. 7