Can ketorolac (nonsteroidal anti-inflammatory drug) be given?

Can Ketorolac Be Given?

Yes, ketorolac can be given for short-term management of moderately severe acute pain requiring opioid-level analgesia, but only for a maximum of 5 days and with careful attention to multiple absolute contraindications and high-risk populations. 1

Absolute Contraindications

Ketorolac is contraindicated in the following situations and must not be given 1, 2:

• Active peptic ulcer disease, recent GI bleeding/perforation, or history of peptic ulcer disease or GI bleeding 1, 2
• Advanced renal impairment or patients at risk for renal failure due to volume depletion 1, 2
• Suspected or confirmed cerebrovascular bleeding 1, 2
• Hemorrhagic diathesis, incomplete hemostasis, or high risk of bleeding 1, 2
• Coronary artery bypass graft (CABG) surgery setting 1, 2
• Labor and delivery (may adversely affect fetal circulation and inhibit uterine contractions) 1, 2
• Previous hypersensitivity to ketorolac, aspirin, or other NSAIDs 1, 2
• Aspirin/NSAID-induced asthma 3, 4
• Pregnancy 3, 4
• Current use of aspirin or other NSAIDs (cumulative risk) 1, 2
• Concomitant use with probenecid or pentoxifylline 2
• As prophylactic analgesic before any major surgery 1, 2
• Intrathecal or epidural administration 1

High-Risk Populations Requiring Extreme Caution

If ketorolac is considered in these populations, use reduced doses and careful monitoring 3, 5:

• Age ≥60 years (use 15 mg IV/IM every 6 hours instead of standard 30 mg dose) 3, 5
• Compromised fluid status or volume depletion 3, 5
• Renal impairment 3
• Concomitant nephrotoxic drugs 3, 5
• History of cardiovascular disease 5
• Significant alcohol use 5
• Concurrent anticoagulant use 5, 4
• Interstitial nephritis or papillary necrosis 3

Dosing Guidelines

Adults (Age 17-64 Years)

• Standard dose: 15-30 mg IV/IM every 6 hours 3
• Maximum daily dose: 120 mg 3
• Maximum duration: 5 days 3, 1

Elderly (≥60 Years)

• Reduced dose: 15 mg IV/IM every 6 hours 3
• Maximum duration: 5 days 3

Pediatric Patients

• Not indicated for use in pediatric patients per FDA labeling 2
• However, clinical guidelines support use in children with 0.5 mg/kg IV bolus, followed by 1.0 mg/kg every 6 hours or 0.17 mg/kg/h infusion (maximum 90 mg/day for 48 hours) 6

Post-Cesarean Delivery

• 30 mg IV at end of surgery, then 30 mg IV every 6 hours for 24 hours, followed by oral ibuprofen 600 mg every 6 hours 3
• Breastfeeding is not a contraindication when used as directed 3

Required Monitoring

Before initiating therapy, obtain 3, 5:

• Baseline blood pressure
• BUN and creatinine
• Liver function tests
• Complete blood count
• Fecal occult blood

For therapy exceeding 3 months (not typical for acute pain), repeat tests every 3 months 3, 5

Clinical Applications Where Ketorolac Is Effective

Ketorolac provides equivalent analgesia to morphine and meperidine for 7, 8:

• Postoperative pain after major abdominal, orthopedic, or gynecological surgery 7
• Renal colic 7, 8
• Migraine headache 7
• Musculoskeletal pain 7
• Sickle cell crisis 7
• Post-tonsillectomy pain 9
• Spinal fusion procedures (safe, does not increase pseudarthrosis risk) 3

Opioid-sparing effect: When combined with opioids, ketorolac reduces opioid requirements by 25-50% 7, 6

Critical Warnings

Gastrointestinal Risk

• Can cause peptic ulcers, GI bleeding, and perforation at any time without warning symptoms 1
• Elderly patients are at greater risk 1
• Risk increases markedly with high doses used >5 days, especially in elderly 7

Cardiovascular Risk

• Increased risk of serious cardiovascular thrombotic events, MI, and stroke 1
• Risk may occur early and increases with duration 1

Renal Risk

• Can cause acute renal failure, usually reversible upon discontinuation 7, 10
• Particular caution in patients with marginal kidney function 9

Bleeding Risk

• Inhibits platelet function reversibly 1, 6
• Bleeding time may be slightly increased 6
• Conflicting evidence regarding post-tonsillectomy bleeding, but most studies show no increased bleeding for other surgeries 6

Hypersensitivity

• Reactions range from bronchospasm to anaphylactic shock 1
• Appropriate counteractive measures must be available when administering first dose 1

Common Pitfalls to Avoid

• Never exceed 5 days of total therapy (combined IV/IM and oral) 1
• Never use in elderly without dose reduction 3, 2
• Never combine with other NSAIDs or aspirin 1, 2
• Never use as pre-emptive analgesia before major surgery 1, 2
• Do not assume faster onset than opioids—analgesic effect may be delayed 30-60 minutes 8
• Recognize that >25% of patients may exhibit little or no response 8