Can patients with gastrointestinal (GI) bleed receive intramuscular (IM) Toradol (ketorolac)?

No, IM Toradol (ketorolac) is absolutely contraindicated in patients with GI bleed

Ketorolac is explicitly contraindicated in patients with active peptic ulcer disease, recent gastrointestinal bleeding or perforation, and in patients with a history of peptic ulcer disease or gastrointestinal bleeding. 1

FDA Black Box Warning

The FDA drug label carries a black box warning specifically addressing this issue:

• Ketorolac is CONTRAINDICATED in patients with active peptic ulcer disease, recent gastrointestinal bleeding or perforation, and in patients with a history of peptic ulcer disease or gastrointestinal bleeding 1
• These serious adverse events (bleeding, ulceration, perforation) can occur at any time during use and without warning symptoms 1
• Only one in five patients who develop a serious upper GI adverse event on NSAID therapy is symptomatic, meaning bleeding can occur without warning 1

Evidence of Extreme Risk

Ketorolac carries the highest gastrotoxicity profile among all NSAIDs:

• Ketorolac presents a 24.7-fold increased risk of upper GI bleeding compared to non-users (95% CI, 9.6-63.5), which is the highest among all NSAIDs 2
• Ketorolac is 5 times more gastrotoxic than all other NSAIDs combined (RR 5.5; 95% CI, 2.1-14.4) 2
• The excess risk with ketorolac is present during the first week of therapy and occurs with both oral and intramuscular administration 2
• Patients with prior GI bleeding are at the highest risk for recurrent bleeding when exposed to NSAIDs, including ketorolac 3

Clinical Decision Algorithm

For patients with recent or active GI bleeding requiring analgesia:

1. First-line: Acetaminophen at maximum doses 3, 4
2. Second-line: Tramadol (safest alternative when acetaminophen fails, no gastric mucosal injury risk) 4
3. Third-line: Duloxetine for central pain modulation 4
4. Last resort: Opioid analgesics if other options insufficient 3

Additional Risk Factors That Amplify Danger

The following factors further increase bleeding risk and make ketorolac use even more dangerous:

• Concurrent antiplatelet therapy (aspirin, clopidogrel) 5, 3
• Anticoagulant use (warfarin, heparin, DOACs) - patients have increased risk of bleeding complications if given ketorolac 1
• Advanced age (elderly patients at greater risk for serious GI events) 1
• Concurrent corticosteroid use 1
• Poor general health status 1

Critical Caveats

• Even a single dose can cause catastrophic bleeding - a case report documented intra-abdominal bleeding requiring exploratory laparotomy after just one dose of ketorolac in a postoperative patient on antiplatelet therapy 6
• The FDA explicitly states that for high-risk patients (including those with GI bleeding history), alternate therapies that do not involve NSAIDs should be considered 1
• Proton pump inhibitors reduce but do not eliminate NSAID-related bleeding risk and are insufficient to safely permit ketorolac use in patients with recent GI bleeding 3, 4
• If NSAIDs become absolutely necessary after complete healing (at least one year from bleeding episode), only consider COX-2 selective inhibitors plus PPI - never ketorolac given its extreme gastrotoxicity 4