Intramuscular Ketorolac (Toradol) for Acute Pain Management
For adults under 65 years, administer 60 mg IM as a single dose or 30 mg IM every 6 hours for multiple dosing (maximum 120 mg/day), with treatment duration not exceeding 5 days. 1
Dosing by Age and Risk Factors
Standard Adult Dosing (Age <65 years, weight ≥50 kg)
- Single-dose regimen: 60 mg IM once 1
- Multiple-dose regimen: 30 mg IM every 6 hours, maximum 120 mg/day 1, 2
- Duration: Maximum 5 days total (combined IM and oral therapy) 1
Reduced Dosing (Age ≥65 years, renal impairment, or weight <50 kg)
- Single-dose regimen: 30 mg IM once 1
- Multiple-dose regimen: 15 mg IM every 6 hours, maximum 60 mg/day 1, 2
- These patients face higher risks of GI bleeding and renal toxicity 2, 3
Administration Technique
- Inject slowly and deeply into muscle 1
- Onset of analgesia begins at approximately 30 minutes, with maximum effect at 1-2 hours 1
- Duration of effect is typically 4-6 hours 1
- Correct hypovolemia before administration to reduce renal risk 1
Clinical Context and Efficacy
Ketorolac IM provides opioid-level analgesia for moderate to severe acute pain, typically in postoperative settings 1. The 30 mg IM dose demonstrates comparable efficacy to morphine 12 mg IM for postoperative pain 4, 5. When used as part of multimodal analgesia, ketorolac exhibits significant opioid-sparing effects, reducing opioid requirements by allowing lower opioid doses while maintaining pain control 6, 2.
IM administration is discouraged compared to IV route because IM injections are painful and offer no pharmacokinetic advantage 7. The IV route is preferred when available 7, 2.
Absolute Contraindications
- Active peptic ulcer disease or GI bleeding 2, 3
- Aspirin or NSAID-induced asthma 2
- Pregnancy 2
- Cerebrovascular hemorrhage 2
- Recent ibuprofen use (wait 6-8 hours after last dose to avoid NSAID stacking and additive toxicity) 3
High-Risk Populations Requiring Caution
- Age ≥60 years (increased GI and renal toxicity risk) 2, 3
- Compromised fluid status or dehydration 2, 3
- Pre-existing renal insufficiency 2, 3
- History of cardiovascular disease or hypertension 3
- Concurrent nephrotoxic medications 2
- Concurrent anticoagulant therapy 3
- Significant alcohol use 3
Monitoring Requirements
Baseline Assessment
- Blood pressure 2, 3
- BUN and creatinine 2, 3
- Liver function tests 2, 3
- Complete blood count 2, 3
- Fecal occult blood 2, 3
Discontinuation Criteria
- BUN or creatinine doubles from baseline 3
- Hypertension develops or worsens 3
- Liver function tests increase >3 times upper limit of normal 3
- Signs of GI bleeding 3
Common Adverse Effects
- Edema 2
- Drowsiness and dizziness 2
- Gastrointestinal upset 2
- Increased diaphoresis 2
- Nausea and headache 8
Unlike opioids, ketorolac does not cause respiratory depression, sedation, urinary retention, or significant nausea/vomiting 6. This makes it particularly valuable for multimodal analgesia strategies 2.
Critical Safety Pitfall
Never combine ketorolac with other NSAIDs (including ibuprofen, naproxen, diclofenac). This increases GI bleeding, renal toxicity, and cardiovascular complications without providing additional analgesic benefit 3. The toxicities are additive, not synergistic for analgesia 3. If a patient has taken ibuprofen, wait 6-8 hours for drug clearance before administering ketorolac 3.
Breakthrough Pain Management
For inadequate pain relief, do not increase ketorolac dose or frequency 1. Instead, supplement with low-dose opioids unless contraindicated 1, 2. Ketorolac has an analgesic ceiling effect, meaning higher doses provide no additional pain relief 8.