What is the recommended dosing for Toradol (ketorolac) for pain management?

Toradol (Ketorolac) Prescribing Guidelines

For adults aged 17-64 years, prescribe ketorolac 20 mg PO once as initial oral dose, followed by 10 mg every 4-6 hours as needed (maximum 40 mg/day), only as continuation therapy after IV/IM ketorolac, with total combined IV/IM and oral duration not exceeding 5 days. 1

Critical Prescribing Rule: Oral Ketorolac is NOT First-Line

• Ketorolac tablets should never be prescribed as initial therapy - they are FDA-approved only as continuation therapy following IV or IM ketorolac administration 1
• The oral formulation cannot be given as an initial dose in any clinical scenario 1

Standard Dosing by Patient Population

Adults Age 17-64 Years (Normal Renal Function, Weight ≥50 kg)

• Initial oral dose: 20 mg PO once (after IV/IM ketorolac) 1
• Maintenance: 10 mg every 4-6 hours as needed 1
• Maximum daily dose: 40 mg/day 1
• Do not shorten the 4-6 hour dosing interval 1

High-Risk Patients (Age ≥65 years, Renal Impairment, or Weight <50 kg)

• Initial oral dose: 10 mg PO once (after IV/IM ketorolac) 1
• Maintenance: 10 mg every 4-6 hours as needed 1
• Maximum daily dose: 40 mg/day 1

Pediatric Patients (Age <17 years)

• Oral ketorolac is not FDA-approved for children 1

Maximum Duration of Therapy

The combined duration of IV/IM and oral ketorolac must not exceed 5 days in adults 1, 2, 3. This strict time limit is essential because:

• Risk of serious adverse events increases significantly with prolonged therapy beyond 5 days 2
• Gastrointestinal bleeding, renal impairment, and operative site bleeding risks escalate with duration 2

Absolute Contraindications

Do not prescribe ketorolac if the patient has: 2, 3

• History of gastrointestinal bleeding or active peptic ulcer disease
• Current risk of gastrointestinal bleeding
• Renal insufficiency or risk of renal failure
• Compromised hemostasis or bleeding diathesis
• Hypersensitivity to aspirin or other NSAIDs
• Concurrent use of other NSAIDs (including ibuprofen, naproxen, etc.)
• Pregnancy, labor, delivery, or breastfeeding
• Concurrent anticoagulant therapy

Critical Drug Interaction: NSAID Stacking

Never prescribe ketorolac concurrently with other NSAIDs - this includes over-the-counter ibuprofen, naproxen, or aspirin 4, 3. The rationale:

• Multiple NSAIDs increase gastrointestinal bleeding, renal toxicity, and cardiovascular complications without providing additional analgesic benefit 4
• Toxicities are additive, not synergistic for analgesia 4

If Patient Recently Took Ibuprofen

• Wait 6-8 hours after the last ibuprofen dose before administering ketorolac to allow adequate drug clearance 4
• Ibuprofen has a 2-hour half-life with peak levels at 1-2 hours post-dose 4
• Consider acetaminophen or opioid analgesics during the waiting period 4

High-Risk Patient Identification

Gastrointestinal Risk Factors 4, 2

• Age ≥60 years
• History of peptic ulcer disease
• Significant alcohol use
• Concurrent anticoagulant therapy

Renal Toxicity Risk Factors 4, 2

• Age ≥60 years
• Dehydration or compromised fluid status
• Pre-existing renal insufficiency
• Concurrent nephrotoxic medications

Cardiovascular Risk Factors 4

• History of cardiovascular disease
• Hypertension
• Concurrent anticoagulation

Required Monitoring

Baseline Assessment 4

• Blood pressure
• BUN and creatinine
• Liver function tests
• Complete blood count
• Fecal occult blood test

Discontinuation Criteria 4

Stop ketorolac immediately if:

• BUN or creatinine doubles from baseline
• Hypertension develops or worsens
• Liver function tests increase >3 times upper limit of normal
• Any gastrointestinal bleeding occurs

Clinical Use Recommendations

Appropriate Indications 3

• Only prescribe for diagnosed injuries or conditions - not prophylactically for anticipated pain 3
• Most effective for bone pain, visceral pain, and musculoskeletal injuries 5
• Should be administered under direct physician supervision 3

Opioid-Sparing Strategy

• Ketorolac exhibits marked opioid-sparing effects when combined with opioids 6
• This combination improves pain relief quality and reduces opioid-related adverse effects (respiratory depression, nausea, ileus) 6
• Consider this approach for postoperative pain management 6

Sample Prescription Format

For a 45-year-old patient (70 kg, normal renal function) after receiving IV ketorolac:

Ketorolac tromethamine 10 mg tablets
Sig: Take 20 mg (two tablets) by mouth once, then 10 mg (one tablet) every 4-6 hours as needed for pain
Disp: #30 tablets
Refills: None
Duration: Do not use for more than 5 days total (including IV/IM doses)

For a 70-year-old patient (48 kg) after receiving IV ketorolac:

Ketorolac tromethamine 10 mg tablets
Sig: Take 10 mg (one tablet) by mouth once, then 10 mg (one tablet) every 4-6 hours as needed for pain
Disp: #20 tablets
Refills: None
Duration: Do not use for more than 5 days total (including IV/IM doses)

Common Prescribing Pitfalls to Avoid

• Never prescribe oral ketorolac as initial therapy - it requires prior IV/IM administration 1
• Never exceed 5 days total duration (IV/IM + oral combined) 1, 2
• Never combine with other NSAIDs - check for concurrent ibuprofen, naproxen, aspirin use 4, 3
• Never prescribe without screening for contraindications - particularly GI bleeding history and renal function 2, 3
• Never use prophylactically - only for diagnosed conditions 3