Can an elderly female patient with normal kidney function and pain related to a motor vehicle accident (MVA) be given Toradol (ketorolac) 60mg intramuscularly (IM)?

Ketorolac 60mg IM in Elderly Female with MVA-Related Pain

Direct Answer

No, an elderly female patient should not receive ketorolac 60mg IM, even with normal kidney function. The FDA-approved maximum dose for elderly patients (≥65 years) is 15mg IV or 30mg IM every 6 hours, with a maximum daily dose of 60mg total—not 60mg as a single dose 1. The 60mg IM dose is only approved for adults under 65 years of age 1.

Age-Specific Dosing Requirements

For patients ≥65 years old, the FDA mandates reduced ketorolac dosing due to increased half-life and risk of adverse events:

• Maximum single dose: 15mg IV or 30mg IM 1
• Dosing interval: Every 6 hours 1
• Maximum daily dose: 60mg total (not per dose) 1
• Maximum treatment duration: 5 days combined IV/IM and oral therapy 1

The pharmacokinetic rationale is clear: elderly patients (65-78 years) demonstrate increased half-life from 5 to 7 hours compared to younger adults, though peak concentrations remain similar 1. This prolonged elimination increases accumulation risk and adverse event potential 1.

Recommended Approach for This Patient

Start with 15mg IV or 30mg IM as a single dose, then reassess:

• Administer the age-appropriate dose (15mg IV or 30mg IM) 2, 1
• Monitor pain relief at 30 minutes to 2 hours 3
• If inadequate analgesia, consider multimodal therapy rather than increasing ketorolac dose 4, 5
• Recent evidence shows 15mg IV or 30mg IM provides equivalent analgesia to higher doses in elderly patients without increased need for rescue analgesia 3

Critical Safety Considerations in Elderly Trauma Patients

NSAIDs carry heightened risks in elderly trauma patients that must be weighed against benefits:

• Gastrointestinal complications: Co-prescribe a proton pump inhibitor if ketorolac is used 4
• Acute kidney injury risk: Despite "normal" baseline function, elderly patients have reduced renal reserve and increased vulnerability to NSAID-induced nephrotoxicity 4
• Drug interactions: Exercise particular caution if patient takes ACE inhibitors, diuretics, or antiplatelets 4
• Bleeding risk: Ketorolac reversibly inhibits platelet aggregation and increases operative site bleeding risk, especially at higher doses and longer duration 6

The World Journal of Emergency Surgery specifically states that NSAIDs "need to be used with caution in elderly patients due to their potential adverse events" and are "usually not recommended" in perioperative pain management of elderly patients with fractures 4.

Alternative First-Line Approach

Consider acetaminophen as the initial analgesic instead:

• Acetaminophen 1000mg IV every 6 hours provides equivalent pain relief to NSAIDs in musculoskeletal trauma without the adverse event profile 5
• A Dutch randomized trial (n=547) confirmed acetaminophen is non-inferior to NSAIDs for minor musculoskeletal trauma 5
• The American College of Emergency Physicians recommends acetaminophen as first-line for acute trauma pain 5
• Acetaminophen has superior safety in elderly patients with minimal contraindications and no renal, gastrointestinal, or cardiovascular toxicity 7

Multimodal Strategy if Additional Analgesia Needed

If acetaminophen alone is insufficient, implement a stepwise approach:

1. Continue scheduled acetaminophen 1000mg IV every 6 hours 5, 7
2. Add low-dose ketorolac (15mg IV or 30mg IM) if no contraindications 2, 1
3. Consider opioids with careful titration starting at lowest dose if severe pain persists 4
4. Add gabapentin or topical agents for neuropathic components 7

The World Journal of Emergency Surgery emphasizes implementing "a multimodal analgesic approach combining acetaminophen with non-pharmacological measures rather than relying solely on NSAIDs" 5.

Common Pitfalls to Avoid

• Never use the standard adult dose (60mg IM) in elderly patients—this violates FDA dosing guidelines and significantly increases adverse event risk 1
• Do not assume "normal kidney function" eliminates NSAID risk—elderly patients have reduced renal reserve despite normal creatinine 4
• Do not prescribe ketorolac without gastroprotection in elderly patients—always co-prescribe a proton pump inhibitor 4
• Do not exceed 5 days total duration of ketorolac therapy (combined parenteral and oral) 1
• Do not use ketorolac if patient has aspirin/NSAID-induced asthma, active peptic ulcer disease, or cerebrovascular hemorrhage 4, 2