What are the contraindications for Toradol (ketorolac)?

Contraindications of Toradol (Ketorolac)

Ketorolac is absolutely contraindicated in patients with active or history of peptic ulcer disease, gastrointestinal bleeding or perforation, advanced renal impairment, cerebrovascular bleeding, hemorrhagic diathesis, aspirin/NSAID-induced asthma, concurrent anticoagulant or NSAID use, labor and delivery, and as prophylactic analgesia before major surgery or in CABG surgery. 1

Absolute Contraindications

Gastrointestinal Contraindications

• Active peptic ulcer disease or history of peptic ulcer disease is an absolute contraindication due to extremely high risk of perforation and life-threatening bleeding 1, 2
• Recent gastrointestinal bleeding or perforation prohibits ketorolac use entirely 1
• Ketorolac carries one of the highest risks of GI toxicity among all NSAIDs, particularly in vulnerable populations 3, 2

Renal Contraindications

• Advanced renal impairment is an absolute contraindication 1
• Patients at risk for renal failure due to volume depletion must not receive ketorolac until volume status is corrected 1, 2
• Acute renal failure occurs in approximately 2% of NSAID users and is typically reversible after discontinuation 3, 4

Bleeding and Coagulation Contraindications

• Suspected or confirmed cerebrovascular bleeding absolutely prohibits ketorolac use 1
• Hemorrhagic diathesis or incomplete hemostasis is a contraindication 1
• Patients at high risk of bleeding, including those with thrombocytopenia, cannot receive ketorolac 1, 2
• Concurrent use with aspirin, other NSAIDs, or anticoagulants is absolutely contraindicated due to cumulative bleeding risks 1, 2

Respiratory Contraindications

• History of asthma, urticaria, or allergic-type reactions after aspirin or other NSAIDs is an absolute contraindication due to risk of severe, rarely fatal anaphylactic-like reactions 1, 5
• Patients with asthma, rhinitis, or nasal polyps require complete avoidance 5, 2

Surgical and Obstetric Contraindications

• Prophylactic analgesic use before any major surgery is contraindicated 1
• Peri-operative pain in CABG surgery is specifically contraindicated 1
• Labor and delivery is contraindicated because ketorolac may adversely affect fetal circulation, inhibit uterine contractions, and increase risk of uterine hemorrhage 1

Drug Interaction Contraindications

• Concomitant use with probenecid is contraindicated 1
• Concomitant use with pentoxifylline is contraindicated 1

High-Risk Populations Requiring Absolute Avoidance

Age-Related Risk

• Patients over 60 years of age face substantially higher risk of serious adverse events, particularly GI perforation and bleeding 2, 3, 6
• The American Geriatrics Society recommends avoiding ketorolac in older adults due to high risk of GI toxicity 7

Cardiovascular Risk

• History of cardiovascular disease or high risk for cardiovascular complications contraindicates ketorolac use 2
• Heart failure is a relative contraindication requiring avoidance in most circumstances 2

Hepatic Risk

• Significant alcohol use history or hepatic dysfunction contraindicates ketorolac due to increased GI toxicity risk 2

Critical Duration and Dosing Limitations

Maximum Treatment Duration

• Treatment must not exceed 5 days under any circumstances 2, 1, 3
• Risk of serious adverse events increases markedly with prolonged therapy beyond 5 days 3, 8

Maximum Daily Dose

• Maximum daily dose must not exceed 120mg 2
• Higher doses dramatically increase risk of GI bleeding, perforation, and renal failure 3, 6

Monitoring Requirements When Use Cannot Be Avoided

If ketorolac must be used despite relative contraindications, mandatory monitoring includes:

• Baseline and serial BUN and creatinine - discontinue if values double 2
• Blood pressure monitoring - discontinue if hypertension develops or worsens 2
• Liver function tests - discontinue if values increase 2
• Complete blood count for detection of thrombocytopenia or anemia 2
• Fecal occult blood testing for early detection of GI bleeding 2

Special Clinical Scenarios

Concurrent Nephrotoxic Drug Use

• Use with other nephrotoxic drugs significantly increases renal toxicity risk and should be avoided 2

Patients Requiring Gastroprotection

• If ketorolac must be used in high-risk patients, proton pump inhibitor co-prescription may reduce GI complication risk, though this does not eliminate contraindications 2

Previous Hypersensitivity

• Any previously demonstrated hypersensitivity to ketorolac is an absolute contraindication 1