Ketorolac (Toradol) Dosing and Management
For moderate to severe acute pain in adults, administer ketorolac 15-30 mg IV every 6 hours (maximum 120 mg/day) for no more than 5 days, with mandatory dose reduction to 15 mg every 6 hours (maximum 60 mg/day) in patients ≥65 years, those with renal impairment, or body weight <50 kg. 1, 2
Standard Dosing Regimens
Multiple-Dose Treatment (Preferred for Ongoing Pain)
Adults <65 years:
High-Risk Populations (≥65 years, renal impairment, <50 kg body weight):
Single-Dose Treatment
IV administration:
IM administration:
Administration Technique
- IV bolus must be given over at least 15 seconds 1
- IM injections should be given slowly and deeply into muscle 1
- Onset of analgesia: 30 minutes; peak effect: 1-2 hours; duration: 4-6 hours 1
Absolute Contraindications
Do not use ketorolac in patients with: 2
- Active peptic ulcer disease or GI bleeding
- History of peptic ulcer disease or GI bleeding
- Advanced renal impairment
- Suspected or confirmed cerebrovascular bleeding
- Hemorrhagic diathesis or high bleeding risk
- Coronary artery bypass graft (CABG) surgery setting
- Aspirin/NSAID-induced asthma or hypersensitivity 3
- Pregnancy, labor, or delivery 2
- Concurrent use with aspirin or other NSAIDs 2
High-Risk Populations Requiring Caution
Use lower doses (15 mg IV q6h) and enhanced monitoring in: 4, 3
- Age ≥60 years
- Compromised fluid status or volume depletion
- Interstitial nephritis or papillary necrosis
- Concomitant nephrotoxic drugs (cyclosporine, cisplatin, aminoglycosides)
- History of cardiovascular disease
- Significant alcohol use (≥2 drinks/day)
- Major organ dysfunction (hepatic, renal)
Critical Duration Limitation
The 5-day maximum duration is non-negotiable because cumulative risks of GI bleeding, renal impairment, and operative site bleeding increase substantially with prolonged therapy. 5, 6 Transition patients to alternative analgesics (oral NSAIDs or other agents) as soon as clinically appropriate. 1
Mandatory Monitoring Protocol
Baseline assessment before initiating therapy: 4, 3
- Blood pressure
- BUN and creatinine
- Liver function tests (alkaline phosphatase, LDH, AST, ALT)
- Complete blood count
- Fecal occult blood
For therapy >3 months (not typical for ketorolac but relevant for chronic NSAID use): Repeat all baseline tests every 3 months 4
Discontinue immediately if: 4
- BUN or creatinine doubles
- Hypertension develops or worsens
- Liver function tests increase >3× upper limit of normal
- Peptic ulcer or GI hemorrhage occurs
- Signs of bleeding complications emerge
Multimodal Analgesia Strategy
Ketorolac works synergistically with opioids, allowing 25-50% reduction in opioid requirements and potentially decreasing opioid-related adverse effects. 7, 8 For breakthrough pain, do not increase ketorolac dose or frequency; instead, supplement with low-dose opioids unless contraindicated. 1
Post-cesarean delivery protocol (if applicable): 3
- 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 when used as directed 3
Evidence on Dose-Response Relationship
Recent high-quality evidence demonstrates no additional analgesic benefit above 10 mg IV, with a randomized controlled trial showing equivalent pain reduction at 10 mg, 15 mg, and 30 mg doses without differences in adverse effects. 9 However, FDA-approved dosing and established guidelines support 15-30 mg dosing, which remains the standard of care. 1, 2
Common Pitfalls to Avoid
- Never exceed 5 days of therapy - this is when serious adverse events markedly increase 6, 7
- Never use in elderly patients without dose reduction - use 15 mg instead of 30 mg 1
- Never mix in syringe with morphine, meperidine, promethazine, or hydroxyzine - causes precipitation 1
- Never use as prophylactic analgesic before major surgery - contraindicated due to bleeding risk 2
- Always correct hypovolemia before administration - reduces renal toxicity risk 1