Ketorolac IM Dosing
For adults under 65 years, administer 60 mg IM as a single dose or 30 mg IM every 6 hours for multiple doses (maximum 120 mg/day); for adults 65 years or older, those with renal impairment, or those weighing less than 50 kg, reduce to 30 mg IM single dose or 15 mg IM every 6 hours (maximum 60 mg/day), with total treatment duration not exceeding 5 days. 1
Standard Adult Dosing (Age <65 years)
Single-Dose Regimen
- 60 mg IM as one-time dose for patients under 65 years of age 1
- Analgesic effect begins in approximately 30 minutes, with maximum effect at 1-2 hours 1
- Duration of analgesia typically lasts 4-6 hours 1
Multiple-Dose Regimen
- 30 mg IM every 6 hours for patients under 65 years 1
- Maximum daily dose: 120 mg 1
- Combined IV/IM and oral ketorolac use must not exceed 5 days total 1
Reduced Dosing for High-Risk Populations
Dose reduction is mandatory for three specific groups 1:
Patients Requiring Lower Doses
Adjusted Dosing Schedule
- Single dose: 30 mg IM (instead of 60 mg) 1
- Multiple doses: 15 mg IM every 6 hours 1
- Maximum daily dose: 60 mg (half the standard maximum) 1
Administration Technique
- Administer slowly and deeply into the muscle 1
- Correct hypovolemia before administration to reduce renal toxicity risk 1
- Peak plasma levels occur at 45-50 minutes after IM injection 2
Duration Limits
The 5-day maximum is absolute and non-negotiable 1:
- Combined duration of IV/IM ketorolac plus oral ketorolac cannot exceed 5 days 1
- Switch to alternative analgesics as soon as clinically appropriate 1
- For cancer pain management, consider short-term use only (maximum 5 days) 3
Contraindications
Absolute contraindications include 4:
- Active peptic ulcer disease or GI bleeding 4
- Aspirin/NSAID-induced asthma 4
- Pregnancy 4
- Cerebrovascular hemorrhage 4
High-Risk Populations Requiring Caution
Gastrointestinal Risk Factors
- Age ≥60 years 3, 4
- History of peptic ulcer disease 3, 4
- Significant alcohol use (≥2 drinks/day) 3
- Concurrent anticoagulant therapy 3, 4
Renal Risk Factors
- Age ≥60 years 3, 4
- Compromised fluid status or dehydration 3, 4
- Interstitial nephritis or papillary necrosis 3, 4
- Concurrent nephrotoxic drugs (cyclosporine, cisplatin) 3, 4
Cardiovascular Risk Factors
Monitoring Requirements
Baseline Assessment
Before initiating ketorolac, obtain 3, 4:
- Blood pressure 3, 4
- BUN and creatinine 3, 4
- Liver function tests (alkaline phosphatase, LDH, SGOT, SGPT) 3, 4
- Complete blood count 3, 4
- Fecal occult blood 3, 4
Discontinuation Criteria
Stop ketorolac immediately if 3, 4:
- BUN or creatinine doubles 3, 4
- Hypertension develops or worsens 3, 4
- Liver function tests increase >3 times upper limit of normal 3, 4
- Gastrointestinal bleeding occurs 3, 4
Multimodal Analgesia Strategy
- Consider supplementing with low-dose opioids for breakthrough pain rather than increasing ketorolac dose or frequency 1
- Ketorolac demonstrates opioid-sparing effects, reducing overall opioid requirements 5, 6
- Unlike opioids, ketorolac does not cause respiratory depression, sedation, nausea/vomiting, or urinary retention 5, 6
Critical Pitfalls to Avoid
NSAID Stacking
- Never combine ketorolac with other NSAIDs (including ibuprofen) due to additive toxicity without additional analgesic benefit 7
- Wait 6-8 hours after last ibuprofen dose before administering ketorolac 7
Dosing Errors
- Do not exceed maximum daily doses (120 mg for standard patients, 60 mg for high-risk) 1
- Do not extend treatment beyond 5 days 1
- Do not use oral ketorolac as initial therapy—it is only for continuation after IV/IM dosing 1
Drug Incompatibility
- Do not mix ketorolac in a syringe with morphine sulfate, meperidine, promethazine, or hydroxyzine—this causes precipitation 1
Special Population: Postoperative Pain
For post-cesarean delivery, the American College of Obstetricians and Gynecologists recommends 4: