Can Toradol and Colchicine Be Used Together?
Yes, Toradol (ketorolac) and colchicine can be used concurrently for acute gout treatment, and this combination is explicitly recommended by major rheumatology guidelines for severe gout attacks, particularly those involving multiple large joints or polyarticular disease. 1
Evidence Supporting Combination Therapy
The American College of Rheumatology specifically endorses initial combination therapy with colchicine and NSAIDs (including ketorolac) for severe gout attacks involving multiple joints. 1 This recommendation is based on the synergistic anti-inflammatory effects of these agents, which target different inflammatory pathways—colchicine inhibits microtubule polymerization and neutrophil migration, while NSAIDs inhibit cyclooxygenase enzymes. 1
The 2017 EULAR guidelines similarly support combination therapy, stating that colchicine and NSAIDs can be combined for particularly severe acute gout when flares involve multiple joints. 2
Dosing Recommendations for Combination Therapy
When using both medications together:
Colchicine: Administer 1.2 mg (or 1 mg) at first sign of flare, followed by 0.6 mg one hour later, then continue 0.6 mg once or twice daily until attack resolves. 1
Ketorolac (Toradol): Use full FDA-approved doses until the gouty attack has completely resolved. 1
After initial treatment, continue prophylactic colchicine dosing (0.6 mg once or twice daily) until the acute attack resolves. 1
Critical Safety Considerations
Renal Function Assessment
Before prescribing this combination, you must assess renal function. Both colchicine and NSAIDs should be avoided in patients with severe renal impairment (GFR <30 mL/min). 2 NSAIDs should be used cautiously in patients with renal disease, heart failure, or cirrhosis. 2
Drug Interaction Screening
Colchicine must not be given to patients receiving strong P-glycoprotein and/or CYP3A4 inhibitors such as cyclosporin, clarithromycin, ketoconazole, or ritonavir. 2 These interactions can increase colchicine plasma concentrations and expose patients to serious toxicity. 2
Cardiovascular Considerations
NSAIDs, including ketorolac, should be avoided in patients with established cardiovascular disease or heart failure due to increased risk of adverse cardiovascular events. 3 In such patients, colchicine alone is preferred, as it is considered safe and may actually reduce the risk of myocardial infarction. 3
When Combination Therapy Is Most Appropriate
The combination is particularly beneficial for:
- Severe gout attacks involving multiple large joints 1
- Polyarticular gout 1
- Patients who can tolerate both medications without contraindications 1
- Early treatment (within 12-36 hours of symptom onset) for maximum effectiveness 1
Common Pitfalls to Avoid
- Do not combine NSAIDs with systemic corticosteroids due to concerns about synergistic gastrointestinal toxicity. 1
- Do not use high-dose colchicine regimens (>1.8 mg in first hour), as they provide no additional benefit but substantially increase gastrointestinal toxicity. 1
- Do not delay treatment beyond 36 hours after symptom onset, as colchicine effectiveness drops significantly beyond this timeframe. 1
- Do not forget to screen for drug interactions before prescribing colchicine, particularly with statins, macrolide antibiotics, and immunosuppressants. 2
Alternative Options If Combination Is Contraindicated
If the patient cannot tolerate both medications: