Toradol (Ketorolac) is Contraindicated in Patients with Ulcers
Ketorolac is absolutely contraindicated in patients with active peptic ulcer disease, recent gastrointestinal bleeding or perforation, and in those with a history of peptic ulcer disease or gastrointestinal bleeding. 1 This is an FDA-mandated black box warning that must be strictly followed.
Why Ketorolac is Particularly Dangerous in Ulcer Patients
Ketorolac carries the highest gastrointestinal bleeding risk among all NSAIDs, with a relative risk of 24.7 compared to non-users, and is 5 times more gastrotoxic than other NSAIDs combined. 2 This extreme risk profile makes it uniquely dangerous:
- The excess risk appears within the first week of therapy and occurs with both oral and intramuscular administration 2
- Even short-term use (5-7 days maximum allowed duration) carries substantial ulceration risk 1, 3
- In elderly patients specifically, ketorolac caused gastric ulcers in 100% of subjects after just 5 days of use in one endoscopic study 3
Clinical Outcomes in Ulcer Patients Exposed to Ketorolac
Multiple case reports document catastrophic outcomes when ketorolac is used in patients with ulcer disease:
- Elderly patients developed perforated gastric ulcers after 13-16 doses, resulting in death from sepsis and multi-organ failure 4
- Patients with prior ulcer history experienced ulcer recurrence and bleeding after as few as 9 doses 4
- The mortality rate for peptic ulcer perforation in NSAID users is already elevated, and ketorolac represents the worst offender in this class 2, 5
What to Do Instead
Very high-risk patients (those with ulcer history) should avoid all NSAIDs entirely. 6 If short-term anti-inflammatory therapy is absolutely required:
- Use corticosteroids instead, as steroids alone do not increase ulcer risk when used without NSAIDs 6
- Consider alternative analgesics, though note that even tramadol may worsen outcomes in patients with peptic ulcer complications 7
- If an NSAID is unavoidable despite the contraindication, the combination of a COX-2 inhibitor plus a PPI and misoprostol offers the best gastrointestinal protection, though this still carries clinically important bleeding risk 6
Critical Pitfalls to Avoid
- Do not assume the intramuscular route is safer - gastrotoxicity occurs equally with IM and oral ketorolac 2
- Do not rely on short duration alone for safety - ulcers and perforations occur within days 3, 4
- Do not use gastroprotection as justification to override the contraindication - the FDA contraindication is absolute and not modified by co-therapy 1
- Ketorolac's maximum allowed duration is 5 days total (IV/IM plus oral combined), but this does not make it safe in contraindicated populations 1
The risk-benefit assessment for ketorolac in patients with ulcer disease is unequivocally unfavorable - the contraindication exists because the mortality and morbidity risks are unacceptably high. 1, 2