Ketorolac Prescription Example for Acute Pain
For acute moderate-to-severe pain in adults aged 17-64 years, prescribe ketorolac 15-30 mg IV/IM every 6 hours (maximum 120 mg/day) for a maximum duration of 5 days only. 1, 2
Standard Adult Dosing (Ages 17-64, Weight >50 kg)
- Initial dose: 15-30 mg IV or IM 1
- Maintenance: 15-30 mg every 6 hours 1
- Maximum daily dose: 120 mg/day 1
- Maximum duration: 5 days total (this is an absolute limit, not a suggestion) 1, 2
Dose Adjustments for High-Risk Populations
For patients ≥65 years, renally impaired, or weight <50 kg, reduce to 15 mg every 6 hours IV/IM only. 1 This lower dose is mandatory, not optional, as elderly patients have significantly higher risk of serious gastrointestinal events and renal complications. 2
Route of Administration
- Preferred route: Intravenous administration for immediate postoperative or acute pain 3
- Alternative: Intramuscular if IV access unavailable 2
- Oral continuation: May transition to oral ketorolac only after initial IV/IM dosing, but combined IV/IM plus oral duration must not exceed 5 days total 2
- Never use: Intrathecal or epidural routes (absolutely contraindicated due to alcohol content) 2
Absolute Contraindications (Do Not Prescribe If Present)
- Active peptic ulcer disease or history of GI bleeding/perforation 4, 2
- Advanced renal impairment or volume depletion 2
- Suspected/confirmed cerebrovascular bleeding 2
- Concurrent anticoagulant or antiplatelet therapy (including aspirin) 4, 2
- History of aspirin/NSAID-induced asthma 4, 5, 2
- Pregnancy or labor/delivery 5, 2
- Coronary artery bypass graft (CABG) surgery setting 2
- Age >60 years with significant alcohol use or hepatic dysfunction 1, 4
- Concurrent use with any other NSAID (toxicities are additive without additional benefit) 1
Required Baseline Monitoring Before Prescribing
Obtain these labs before initiating ketorolac: 1
- Blood pressure
- BUN and creatinine
- Liver function tests
- Complete blood count
- Fecal occult blood test
Mandatory Discontinuation Criteria
Stop ketorolac immediately if any of the following occur: 1, 4
- BUN or creatinine doubles from baseline
- Hypertension develops or worsens
- Liver function tests increase >3× upper limit of normal
- Any signs of gastrointestinal bleeding
Clinical Context and Alternatives
Ketorolac should be reserved for situations where standard NSAIDs have failed or are insufficient. 1 Standard NSAIDs like ibuprofen 600 mg up to 4 times daily have superior safety profiles for sustained use and should be first-line. 1
In emergency department settings, ketorolac provides analgesia equivalent to morphine or meperidine for conditions like renal colic, but has a delayed onset of 30-60 minutes and >25% of patients exhibit little or no response. 6 For postoperative pain, ketorolac combined with opioids reduces opioid requirements by 25-50%, potentially decreasing opioid-related adverse events. 7
For acute low back pain specifically, oral ketorolac was superior to acetaminophen/codeine with fewer adverse events (34% vs 64%) and better tolerability. 8
Sample Prescription Format
Ketorolac tromethamine 30 mg IV
- Administer 30 mg IV every 6 hours as needed for pain
- Maximum daily dose: 120 mg
- Maximum duration: 5 days
- Indication: Acute moderate-to-severe pain
- Contraindications reviewed and none present
- Baseline labs obtained (date: ___)
Critical Safety Warning
Never combine ketorolac with other NSAIDs (including ibuprofen, naproxen, or aspirin) as toxicities are additive without providing additional analgesic benefit, significantly increasing risks of GI bleeding, renal failure, and cardiovascular events. 1 This is one of the most common and dangerous prescribing errors with ketorolac.