What should I do if I'm already taking ketorolac (Toradol) with rivaroxaban (Xarelto)?

Immediate Action Required: Discontinue Ketorolac

You must stop taking ketorolac (Toradol) immediately while on rivaroxaban (Xarelto) due to the substantially increased risk of serious bleeding complications. 1

Why This Combination Is Dangerous

The combination of rivaroxaban and NSAIDs like ketorolac creates additive bleeding risk through two distinct mechanisms:

• Rivaroxaban inhibits Factor Xa, preventing clot formation through the coagulation cascade 2
• Ketorolac impairs platelet function and hemostasis through COX-1 inhibition, which is essential for vascular hemostasis 1
• Together, these effects are additive, meaning the bleeding risk is substantially higher than either drug alone 1

Evidence Against This Combination

Guideline Recommendations

• The British Society of Gastroenterology and European Society of Gastrointestinal Endoscopy explicitly state that non-steroidal anti-inflammatory drugs should be avoided with rivaroxaban, as their concomitant use was associated with increased bleeding risk 2
• The International Society on Thrombosis and Haemostasis guidelines recommend careful evaluation of any drug combinations that may increase bleeding risk 1

Specific Risks with Ketorolac

• Ketorolac is a potent antiplatelet medication with documented risks of gastrointestinal bleeding, operative site bleeding, and altered hemostasis 3, 4
• The risk of serious bleeding increases markedly with ketorolac, especially when combined with other medications affecting hemostasis 3
• Case reports document severe complications including spinal epidural hematoma when ketorolac is combined with other factors affecting hemostasis 4

What You Should Do Now

Step 1: Stop Ketorolac Immediately

• Discontinue ketorolac right away 1
• Do not take any additional doses

Step 2: Contact Your Prescribing Physician

• Inform them you have been taking both medications concurrently
• Discuss why you were prescribed ketorolac and what alternatives exist

Step 3: Monitor for Bleeding Signs

Watch for and report immediately any of the following 1:

• Unusual bruising or bleeding
• Prolonged bleeding from cuts
• Black or tarry stools
• Blood in urine
• Coughing up blood
• Severe headache or dizziness

Step 4: Consider Safer Alternatives

If you need pain relief while on rivaroxaban:

• COX-2 selective inhibitors (such as celecoxib) provide anti-inflammatory effects with lower platelet dysfunction and GI bleeding risk compared to non-selective NSAIDs like ketorolac 1
• Acetaminophen (paracetamol) is generally safer for pain relief in anticoagulated patients 5
• Discuss with your physician which alternative is most appropriate for your specific pain condition

Critical Pitfall to Avoid

Never use "triple therapy" (rivaroxaban + NSAID + antiplatelet agent like aspirin) as this substantially increases bleeding risk beyond acceptable levels 1

Additional Risk Factors That Worsen This Combination

You are at even higher risk if you have any of the following 1:

• Moderate renal impairment (CrCl 15-49 mL/min) - both drugs have altered pharmacokinetics
• Liver cirrhosis or elevated liver enzymes >2x upper limit of normal
• Elderly age (>65 years)
• History of previous bleeding episodes
• Low body weight (<50 kg)