Can I administer Toradol (Ketorolac) 15 mg if I have already given 400 mg of Ibuprofen (Nonsteroidal Anti-Inflammatory Drug)?

From the Guidelines

It is not recommended to give toradol 15 mg if 400 mg ibuprofen has already been given. These medications belong to the same class of drugs called non-steroidal anti-inflammatory drugs (NSAIDs), and taking them together increases the risk of side effects without providing additional pain relief benefits, as noted in a study on adult cancer pain management 1. Taking multiple NSAIDs simultaneously can increase the risk of gastrointestinal bleeding, stomach ulcers, kidney problems, and cardiovascular issues. Some key points to consider when prescribing NSAIDs include:

• Using any NSAID that the patient has found effective and tolerated well in the past, otherwise considering ibuprofen to the maximal dose, as suggested in the study 1
• Considering short-term use of ketorolac, but only when necessary and with caution, due to the potential for increased side effects
• Being aware of the potential side effects of chemotherapy, such as hematologic, renal, hepatic, and cardiovascular toxicities, which can be increased by the concomitant prescription of NSAIDs, as noted in the study 1 If ibuprofen isn't providing adequate pain relief, it is recommended to wait until the ibuprofen dose has worn off (typically 6-8 hours after taking it) before considering toradol, and only do so under medical supervision. Alternatively, you could consider adding a different type of pain reliever such as acetaminophen (Tylenol), which works through a different mechanism and can be safely combined with NSAIDs. Always consult with a healthcare provider before combining pain medications or switching between them.

From the FDA Drug Label

In vitro studies indicate that, at therapeutic concentrations of salicylate (300 mcg/mL), the binding of ketorolac was reduced from approximately 99.2% to 97. 5%, representing a potential twofold increase in unbound ketorolac plasma levels. Therapeutic concentrations of digoxin, warfarin, ibuprofen, naproxen, piroxicam, acetaminophen, phenytoin and tolbutamide did not alter ketorolac tromethamine protein binding

• Key Point: The FDA label does mention the interaction between ketorolac and ibuprofen, stating that therapeutic concentrations of ibuprofen do not alter ketorolac tromethamine protein binding.
• Answer: Based on the information provided, it appears that giving toradol (ketorolac) 15 mg after giving 400 mg ibuprofen may not have a significant interaction in terms of protein binding. However, caution is advised when co-administering NSAIDs due to the potential increased risk of adverse effects, such as gastrointestinal bleeding 2.

From the Research

Interaction between Toradol and Ibuprofen

• The use of multiple nonsteroidal anti-inflammatory drugs (NSAIDs) such as Toradol (ketorolac) and ibuprofen can increase the risk of adverse effects, including gastrointestinal bleeding, acute renal failure, and hepatic injury 3.
• A study found that the concomitant use of two or more NSAIDs was associated with an excess risk of adverse effects, including hepatic injury, acute renal failure, and gastrointestinal bleeding 3.
• The risk of adverse events associated with NSAID use increases with high doses, prolonged therapy, or in vulnerable patients, such as the elderly 4.

Dosing Considerations

• If 400 mg of ibuprofen has been administered, it is essential to consider the potential risks of adding another NSAID like Toradol (ketorolac) to the treatment regimen.
• The dosage guidelines for Toradol recommend using the lowest effective dose for the shortest duration possible to minimize the risk of adverse effects 4.
• There is no specific guidance on the concomitant use of Toradol and ibuprofen in the provided studies, but it is crucial to exercise caution when using multiple NSAIDs due to the increased risk of adverse effects.

Alternative Treatment Options

• Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and Toradol can be effective for acute pain management, but it is essential to consider alternative treatment options, such as acetaminophen, to minimize the risk of adverse effects 5.
• Combination therapy using a small amount of opioid together with a nonopioid pain reliever has been shown to be effective and reduces opioid consumption 5.