Is it safe to give Toradol (ketorolac) to a patient with a known allergy to ibuprofen?

No, you should NOT give Toradol (ketorolac) to a patient with a known ibuprofen allergy

Ketorolac is absolutely contraindicated in patients with a history of allergic-type reactions to aspirin or other NSAIDs, including ibuprofen, due to the risk of severe, potentially fatal anaphylactic-like reactions. 1

Why Cross-Reactivity Occurs

Both ibuprofen and ketorolac belong to the NSAID class and share similar mechanisms of action through COX enzyme inhibition. 2 Specifically:

• Ibuprofen is classified as a propionic acid derivative 2
• Ketorolac is classified as an acetic acid derivative 2

While they belong to different chemical subclasses, cross-reactivity between NSAID classes is well-documented and unpredictable, particularly for true allergic (IgE-mediated or T-cell mediated) hypersensitivity reactions. 2

FDA Contraindication

The FDA drug label explicitly states: "Ketorolac tromethamine should not be given to patients who have experienced asthma, urticaria, or allergic-type reactions after taking aspirin or other NSAIDs. Severe, rarely fatal, anaphylactic-like reactions to NSAIDs have been reported in such patients." 1

Types of NSAID Hypersensitivity Reactions

Understanding the type of reaction your patient experienced with ibuprofen is critical:

Immediate Reactions (within 6 hours):

• Anaphylaxis/anaphylactoid reactions: urticaria, angioedema, bronchospasm, hypotension 2, 1
• Respiratory reactions: bronchospasm, asthma exacerbation 2, 3
• These reactions carry high risk of cross-reactivity across all NSAIDs 2

Delayed Reactions (>6 hours to weeks):

• Maculopapular rash, fixed drug eruption, Stevens-Johnson syndrome/TEN 2
• Aseptic meningitis (more common with ibuprofen specifically) 2
• Drug-induced interstitial nephritis 2

Clinical Case Reports

A documented case exists of a patient with ibuprofen allergy who developed severe anaphylactoid reaction to ketorolac, presenting with systemic urticaria, tachycardia, bronchospasm, and oxygen desaturation requiring aggressive treatment with antihistamines, steroids, aminophylline, and CPAP. 4

This case demonstrates that cross-reactivity between ibuprofen and ketorolac is not theoretical—it occurs in clinical practice with life-threatening consequences. 4

Safer Alternative Analgesic Options

Instead of ketorolac, consider these alternatives:

First-Line Alternatives:

• Acetaminophen up to 4g daily (no cross-reactivity with NSAIDs) 2, 5
• Opioids (morphine, hydromorphone, fentanyl) if pain severity warrants 2, 5

For Specific Clinical Scenarios:

• Tramadol 50mg orally for moderate pain 2
• Topical lidocaine for localized pain 2
• Regional anesthesia techniques when appropriate 5

If NSAID Absolutely Required:

• Formal allergy evaluation with graded challenge or desensitization protocol under controlled conditions 2
• This should only be performed by allergist-immunologists in monitored settings 2

Common Pitfalls to Avoid

• Do not assume different NSAID chemical classes are safe—cross-reactivity occurs unpredictably 2
• Do not rely on the patient's ability to distinguish between side effects and true allergic reactions—obtain detailed history of the reaction type 2, 3
• Do not administer ketorolac without specifically asking about aspirin/NSAID intolerance, asthma, rhinitis, and nasal polyps 3
• Do not confuse NSAID-exacerbated respiratory disease (NERD/AERD) with true allergy—both are contraindications to ketorolac 2, 1

Emergency Preparedness

If ketorolac were mistakenly administered to this patient, be prepared for:

• Immediate anaphylaxis with urticaria, angioedema, bronchospasm, hypotension 1, 4
• Treatment: epinephrine, antihistamines, corticosteroids, bronchodilators, airway support 4
• Monitoring: continuous vital signs, oxygen saturation, respiratory status 4