What is the recommended dosing for ketorolac (Toradol) administration?

Ketorolac Administration Guidelines

Recommended Dosing Regimen

For adults under 65 years, administer ketorolac 30 mg IV over at least 15 seconds or 30 mg IM as a single dose, or 30 mg every 6 hours (maximum 120 mg/day) for multiple doses; for adults 65 years and older, patients with renal impairment, or those weighing less than 50 kg, reduce the dose to 15 mg IV or 30 mg IM every 6 hours (maximum 60 mg/day). 1

Route-Specific Administration

Intravenous Administration

• Administer IV bolus over no less than 15 seconds 1
• Single dose for patients <65 years: 30 mg 1
• Single dose for patients ≥65 years, renally impaired, or <50 kg: 15 mg 1
• Multiple dosing <65 years: 30 mg every 6 hours 1
• Multiple dosing ≥65 years or high-risk patients: 15 mg every 6 hours 1

Intramuscular Administration

• Inject slowly and deeply into the muscle 1
• Single dose for patients <65 years: 60 mg 1
• Single dose for patients ≥65 years, renally impaired, or <50 kg: 30 mg 1
• Multiple dosing follows same frequency as IV route 1

Pediatric Dosing

• Recommended IV dose: 0.5 mg/kg, followed by 1.0 mg/kg every 6 hours or continuous infusion of 0.17 mg/kg/hour 2
• Maximum daily dose: 90 mg 2
• Maximum treatment duration: 48 hours 2
• Not recommended for infants under 1 year of age 2

Critical Timing Considerations

NSAID Interaction Management

If the patient has recently taken ibuprofen or another NSAID, wait 6-8 hours after the last dose before administering ketorolac to avoid additive toxicity. 3

• Concurrent NSAID use increases risk of gastrointestinal bleeding, renal toxicity, and cardiovascular complications without additional analgesic benefit 3
• Ibuprofen has a 2-hour half-life; minimum clearance requires 6-8 hours 3
• Consider acetaminophen or opioid analgesics during the waiting period 3

Duration Limits

Do not exceed 5 days of ketorolac therapy; switch to alternative analgesics as soon as possible. 1

Onset and Duration of Action

• Analgesic effect begins in approximately 30 minutes 1
• Maximum effect occurs 1-2 hours after administration 1
• Duration of analgesia: 4-6 hours 1

Pre-Administration Requirements

Mandatory Corrections

• Correct hypovolemia before administering ketorolac 1

Baseline Assessment

• Blood pressure, BUN, creatinine 3
• Liver function tests, CBC, fecal occult blood 3

High-Risk Patient Modifications

Contraindications and Cautions

Avoid or use extreme caution in patients with:

• Age ≥60 years (use reduced dosing) 3, 1
• History of peptic ulcer disease or gastrointestinal bleeding 3
• Pre-existing renal insufficiency 3
• Cardiovascular disease or hypertension 3
• Concurrent anticoagulant therapy 3
• Significant alcohol use 3
• Pregnancy or breastfeeding 4

Monitoring During Therapy

Discontinuation Criteria

Stop ketorolac immediately if:

• BUN or creatinine doubles from baseline 3
• Hypertension develops or worsens 3
• Liver function tests increase >3 times upper limit of normal 3
• Gastrointestinal bleeding occurs 3

Dosing Ceiling Effect

Recent evidence demonstrates that 10 mg IV ketorolac provides equivalent analgesia to 15 mg and 30 mg doses, suggesting an analgesic ceiling at 10 mg. 4

• A 2017 randomized controlled trial showed no difference in pain reduction at 30 minutes between 10 mg, 15 mg, and 30 mg IV doses 4
• Despite this evidence, FDA labeling still recommends higher doses, and clinical practice patterns show 97% of IV doses exceed 10 mg 1, 5
• For elderly patients (≥65 years), low-dose ketorolac (15 mg IV or 30 mg IM) demonstrated similar efficacy to higher doses (30 mg IV or 60 mg IM) without increased need for rescue analgesia 6

Combination Therapy

Opioid-Sparing Strategy

• Ketorolac exhibits marked opioid-sparing effects when combined with opioids 2
• Consider supplementing with low-dose opioids for breakthrough pain rather than increasing ketorolac dose or frequency 1
• This combination improves pain relief quality while reducing opioid-related adverse effects 2

Drug Compatibility

Do not mix ketorolac in a syringe with morphine sulfate, meperidine, promethazine, or hydroxyzine, as this causes precipitation. 1

Common Pitfalls to Avoid

• Do not administer IM injections in children unless IV route is unavailable 2
• Do not increase dose or frequency for breakthrough pain; instead, add supplemental analgesics 1
• Do not combine with other NSAIDs, as toxicities are additive without synergistic analgesia 3
• Do not exceed maximum daily doses: 120 mg/day for patients <65 years, 60 mg/day for patients ≥65 years or high-risk populations 1