Immediate Action Required: Discontinue Toradol Now
A patient who has been taking Toradol (ketorolac) PO for 5 days has reached the maximum allowable duration and must discontinue the medication immediately. 1 The FDA label explicitly states that the total combined duration of ketorolac use (IV/IM plus oral) must not exceed 5 days due to the potential for increasing frequency and severity of adverse reactions. 1
Why 5 Days is the Hard Stop
The 5-day maximum is an absolute limit, not a guideline. Both the FDA drug label and multiple clinical guidelines (American Academy of Family Physicians, National Comprehensive Cancer Network) consistently emphasize that ketorolac treatment should not exceed 5 days under any circumstances. 2, 1
Risk escalation occurs rapidly after day 5. The incidence of serious adverse events—particularly gastrointestinal bleeding, renal impairment, and cardiovascular complications—increases markedly with prolonged therapy beyond 5 days, especially in vulnerable populations. 3, 4
Gastrointestinal toxicity is particularly concerning. Ketorolac carries one of the highest risks of GI toxicity among all NSAIDs, with risk increasing substantially with duration of therapy. 2 The combination of prolonged half-life and significant enterohepatic circulation leads to extended mucosal exposure and greater GI damage. 2
Immediate Steps at Day 5
Discontinue ketorolac immediately and transition to alternative analgesia. 1 The patient should be switched to alternative analgesics as soon as possible, with no exceptions for continuing beyond 5 days. 1
Before Discontinuation: Assess for Complications
Evaluate the patient for signs of ketorolac-related toxicity that may have developed during the 5-day course:
Check renal function: Measure BUN and creatinine. Discontinue immediately if BUN or creatinine has doubled from baseline. 2, 5
Assess for GI bleeding: Check for signs of gastrointestinal bleeding (melena, hematemesis, abdominal pain) and consider fecal occult blood testing. 2
Monitor blood pressure: Ketorolac can cause mean blood pressure increases of approximately 5 mm Hg. Discontinue if hypertension has developed or worsened. 2, 5
Review liver function: If liver function tests have increased >3× upper limit of normal, this is an indication for immediate discontinuation. 5
Transition to Alternative Analgesia
First-Line Alternatives for Continued Pain Management
Standard NSAIDs with better safety profiles such as ibuprofen (600 mg up to 4 times daily), etodolac, or nabumetone are recommended for sustained use if NSAID therapy is still needed. 2, 5 These have significantly better safety profiles than ketorolac for extended use.
Acetaminophen up to 4g daily is a safer alternative, though blood pressure effects should be monitored. 2
Never combine ketorolac with other NSAIDs (including ibuprofen), as toxicities are additive without providing additional analgesic benefit, significantly increasing risks of GI bleeding, renal failure, and cardiovascular events. 5
For Severe Pain Requiring Stronger Analgesia
Low-dose oral opioids may be considered if pain remains severe and NSAIDs/acetaminophen are insufficient. 2 However, opioid prescribing should be limited to short-acting, low-potency medications for a few days only, as even short-term opioid therapy carries risks of adverse effects and potential for opioid use disorder. 6
Multimodal analgesia combining acetaminophen with standard NSAIDs (not ketorolac) provides superior pain control without the extreme toxicity risks of prolonged ketorolac use. 7
For Neuropathic Pain Components
If the pain has a neuropathic component, consider adding coanalgesics:
- Gabapentin: Start 100-300 mg nightly, titrate to 900-3600 mg/day in divided doses. 5
- Pregabalin: Start 50 mg three times daily, increase to 100 mg three times daily. 5
- Tricyclic antidepressants: Nortriptyline 10-25 mg nightly, increase to 50-150 mg. 5
Critical Safety Considerations
High-Risk Populations Requiring Extra Vigilance
Patients ≥60 years old are at significantly elevated risk for GI bleeding and should have been monitored more closely throughout the 5-day course. 2
Patients with cardiovascular disease, hypertension, or heart failure are at increased risk for cardiovascular events and blood pressure elevation. 2
Patients with any degree of renal impairment are at risk for acute renal failure, which is usually reversible after discontinuation but requires monitoring. 3, 4
Common Pitfall to Avoid
Do not restart ketorolac after a brief washout period. The 5-day maximum is cumulative and absolute. If pain persists requiring NSAID therapy, transition to a different NSAID with a better safety profile for longer-term use, not another course of ketorolac. 2
Documentation and Patient Education
Document the reason for discontinuation (completion of maximum 5-day course) and the transition plan to alternative analgesia.
Educate the patient that ketorolac cannot be continued beyond 5 days due to serious safety concerns, and explain the alternative pain management strategy.
Advise the patient to report any signs of GI bleeding (black stools, bloody vomit), worsening abdominal pain, decreased urine output, or significant blood pressure changes in the days following discontinuation.