What is the recommended intramuscular dose of Toradol (ketorolac) for an adult patient with back pain and no significant contraindications to Non-Steroidal Anti-Inflammatory Drug (NSAID) use?

Recommended Intramuscular Dose of Ketorolac for Back Pain

For adults under 65 years with back pain, administer ketorolac 30 mg IM every 6 hours (maximum 120 mg/day), and for adults 65 years or older, use 15 mg IM every 6 hours (maximum 60 mg/day), with treatment duration not exceeding 5 days. 1

Standard Dosing Protocol

Adults Under 65 Years

• 30 mg IM every 6 hours is the FDA-approved dose for multiple-dose treatment 1
• Maximum daily dose: 120 mg 1
• Single-dose option: 60 mg IM (for one-time use only) 1
• Administer slowly and deeply into the muscle 1

Adults 65 Years or Older

• 15 mg IM every 6 hours (reduced dose due to increased risk) 1
• Maximum daily dose: 60 mg 1
• Single-dose option: 30 mg IM 1
• The American Geriatrics Society emphasizes extreme caution in this population due to increased risk of all NSAID-related adverse effects 2

Patients Under 50 kg (110 lbs) or with Renal Impairment

• Use the reduced dosing regimen: 15 mg IM every 6 hours (maximum 60 mg/day) 1
• These patients have the same risk profile as elderly patients 1

Critical Duration Limitation

• Maximum treatment duration: 5 days for all patients 2, 1
• Switch to oral NSAIDs or alternative analgesics as soon as possible 1
• The National Comprehensive Cancer Network emphasizes that ketorolac should be used for the shortest duration necessary 2

Evidence Supporting Ketorolac for Back Pain

Efficacy Data

• Ketorolac demonstrated superior efficacy compared to acetaminophen-codeine for acute low back pain in the emergency department, with comparable pain relief but significantly fewer adverse events 3
• NSAIDs (including ketorolac) are superior to placebo for pain relief and functional improvement in acute low back pain 4
• The American College of Physicians recommends NSAIDs as first-line agents for low back pain, noting they are slightly superior to acetaminophen 5

Analgesic Ceiling Effect

• Research demonstrates an analgesic ceiling effect at doses as low as 7.5-10 mg, meaning higher doses do not provide additional pain relief 6, 7
• Despite this evidence, the FDA-approved dosing remains 30 mg for standard adult patients, which should be followed for medicolegal reasons 1
• A study in patients 65 years and older found no significant difference in pain relief between 15 mg and 30 mg doses 8

Pre-Administration Safety Assessment

Absolute Contraindications

• Active peptic ulcer disease or gastrointestinal bleeding 2
• Aspirin/NSAID-induced asthma 2
• Pregnancy 2
• Recent cerebrovascular hemorrhage 2
• Perioperative pain in coronary artery bypass graft surgery 4

High-Risk Populations Requiring Caution

• Age ≥60 years: Increased risk of all NSAID-related adverse effects 9
• Renal impairment: Use 15 mg dose; ketorolac causes renal dysfunction in 8.7% of high-risk patients 9, 2
• Compromised fluid status or dehydration: Correct hypovolemia before administration 1
• History of peptic ulcer disease: 5% risk of recurrent bleeding within 6 months 4
• Concurrent anticoagulant use: Increases GI bleeding risk 5-6 fold 4
• Cardiovascular disease or hypertension: NSAIDs increase myocardial infarction risk 5

Mandatory Monitoring Requirements

Baseline Assessment (Before First Dose)

• Blood pressure 9, 2
• BUN and creatinine 9, 2
• Liver function tests 9, 2
• Complete blood count 9, 2
• Fecal occult blood 9, 2

Discontinuation Criteria

• Stop immediately if:
  • BUN or creatinine doubles 9
  • Hypertension develops or worsens 9
  • Liver function tests increase >3 times upper limit of normal 9
  • Any gastrointestinal bleeding occurs 9, 4

Onset and Duration of Action

• Analgesic effect begins in approximately 30 minutes 1
• Maximum effect occurs 1-2 hours after IM administration 1, 10
• Duration of analgesic effect: 4-6 hours 1
• Peak plasma concentrations achieved in 45-50 minutes 10

Multimodal Analgesia Strategy

For Breakthrough Pain

• Do not increase ketorolac dose or frequency 1
• Consider supplementing with low-dose opioids if not contraindicated 1
• Acetaminophen can be safely alternated with ketorolac every 3 hours for more continuous coverage 9

Transition Strategy

• After 5 days maximum, transition to oral NSAIDs (e.g., ibuprofen 400-800 mg every 6 hours, maximum 2400 mg/day) 4
• Acetaminophen is a safer long-term alternative with fewer side effects, though slightly less effective 5

Common Pitfalls to Avoid

• Avoid combining with other NSAIDs (including ibuprofen): Wait 6-8 hours after last ibuprofen dose before giving ketorolac due to additive toxicity without additional analgesic benefit 9
• Do not mix in syringe with morphine sulfate, meperidine, promethazine, or hydroxyzine (causes precipitation) 1
• Do not exceed 5-day duration: Risk-benefit ratio deteriorates significantly with prolonged use 4
• Do not use standard doses in elderly or renally impaired patients: Always use reduced 15 mg dosing 1