What is the recommended dose of ketorolac (Toradol) for pain management?

Ketorolac Dosing for Pain Management

For adults under 65 years, administer ketorolac 15-30 mg IV/IM every 6 hours (maximum 120 mg/day), while patients 65 years or older, those with renal impairment, or weighing less than 50 kg should receive 15 mg IV/IM every 6 hours (maximum 60 mg/day), with treatment duration strictly limited to 5 days maximum. 1, 2

Standard Adult Dosing (Age 17-64 years, >50 kg)

Multiple-dose regimen:

• 15-30 mg IV or IM every 6 hours 1, 2
• Maximum daily dose: 120 mg 1, 2
• Duration: Not to exceed 5 days 1, 2

Single-dose regimen:

• IM: 60 mg (one-time dose) 2
• IV: 30 mg (one-time dose) 2

Reduced Dosing for High-Risk Populations

Patients ≥65 years, renally impaired, or <50 kg (110 lbs):

• 15 mg IV/IM every 6 hours 1, 2
• Maximum daily dose: 60 mg 1, 2
• Single-dose: 30 mg IM or 15 mg IV 2

The American Geriatrics Society specifically emphasizes extreme caution in elderly patients due to increased risk of acute renal failure 1.

Administration Technique

• IV bolus must be given over at least 15 seconds 2
• IM injections should be administered slowly and deeply into muscle 2
• Analgesic effect begins in approximately 30 minutes, with maximum effect at 1-2 hours 2
• Duration of effect: 4-6 hours 2

Critical Contraindications

Absolute contraindications include: 1, 3

• Active peptic ulcer disease or GI bleeding
• Aspirin/NSAID-induced asthma
• Pregnancy
• Cerebrovascular hemorrhage
• Recent ibuprofen use (wait 6-8 hours after last dose) 3

Important Clinical Caveat: The Analgesic Ceiling Effect

Despite FDA labeling recommending 30 mg doses, high-quality research demonstrates that 10 mg IV ketorolac provides equivalent analgesia to 15 mg and 30 mg doses. 4 A 2017 randomized controlled trial of 240 ED patients showed no difference in pain reduction between 10 mg, 15 mg, and 30 mg doses at 30 minutes, with similar rescue analgesia rates and adverse effects 4. However, current guideline recommendations from the American Academy of Family Physicians and FDA labeling continue to support 15-30 mg dosing 1, 2, and real-world practice patterns show 97% of IV doses exceed 10 mg 5.

In clinical practice, follow the guideline-recommended 15-30 mg dosing, but recognize that lower doses may provide equivalent analgesia with potentially reduced toxicity risk.

Mandatory Monitoring Requirements

Baseline assessment before initiating therapy: 1, 3

• Blood pressure
• BUN and creatinine
• Liver function tests
• CBC
• Fecal occult blood

Discontinue immediately if: 3

• BUN or creatinine doubles
• Hypertension develops or worsens
• LFTs increase >3 times upper limit of normal
• GI bleeding occurs

Special Population: Post-Cesarean Delivery

The American College of Obstetricians and Gynecologists recommends a specific regimen: 1

• 30 mg IV at end of surgery
• Followed by 30 mg IV every 6 hours for 24 hours
• Then transition to oral ibuprofen 600 mg every 6 hours
• Breastfeeding is not a contraindication 1

Avoiding NSAID Stacking

Never combine ketorolac with other NSAIDs (including ibuprofen). 3 The National Comprehensive Cancer Network emphasizes that concurrent NSAID use increases GI bleeding, renal toxicity, and cardiovascular complications without additional analgesic benefit 3. If a patient has taken ibuprofen, wait 6-8 hours before administering ketorolac 3.

Multimodal Analgesia Strategy

For breakthrough pain, do not increase ketorolac dose or frequency. 2 Instead, supplement with low-dose opioids unless contraindicated 2. The Enhanced Recovery After Surgery Society supports combining ketorolac with IV fentanyl for improved postoperative analgesia 1.