Does the use of a heparin drip and Toradol (ketorolac) increase the risk of bleeding?

From the Guidelines

The combination of a heparin drip and toradol should be used with caution due to the increased risk of bleeding, as both medications can have additive effects on bleeding risk through different mechanisms. The use of heparin, an anticoagulant, and toradol, a non-steroidal anti-inflammatory drug (NSAID), can increase the risk of bleeding in patients, especially those with existing bleeding risk factors such as advanced age, renal impairment, history of GI bleeding, or concurrent use of other medications affecting hemostasis 1. According to the American College of Physicians, heparin and related drugs are associated with an increased risk for bleeding, and risk factors for bleeding with anticoagulant therapy include older age, female sex, diabetes, hypertension, presence of cancer, and concomitant use of aspirin, nonsteroidal anti-inflammatory drugs, antiplatelet agents, antibiotics, statins, fibrates, and steroids 1.

When considering the use of a heparin drip and toradol, it is essential to weigh the benefits of venous thromboembolism prophylaxis against the potential risks of bleeding. The American College of Physicians recommends pharmacologic prophylaxis with heparin or a related drug for venous thromboembolism in medical patients unless the assessed risk for bleeding outweighs the likely benefits 1. Key factors to consider when assessing the risk of bleeding include:

• Patient age and comorbidities
• History of bleeding or bleeding disorders
• Use of concurrent medications that affect hemostasis
• Presence of cancer or other conditions that increase the risk of bleeding
• Renal impairment or liver disease

Close monitoring for signs of bleeding is crucial when using a heparin drip and toradol, including:

• Checking for occult blood in stool
• Monitoring hemoglobin levels
• Watching for bruising or other bleeding manifestations
• Regularly assessing the patient's overall clinical condition and adjusting the treatment plan as needed.

From the FDA Drug Label

The concurrent use of ketorolac tromethamine and therapy that affects hemostasis, including prophylactic low-dose heparin (2500 to 5000 units q12h), warfarin and dextrans have not been studied extensively, but may also be associated with an increased risk of bleeding Patients on therapeutic doses of anticoagulants (e.g., heparin or dicumarol derivatives) have an increased risk of bleeding complications if given ketorolac tromethamine concurrently; therefore, physicians should administer such concomitant therapy only extremely cautiously Hemorrhage can occur at virtually any site in patients receiving heparin. A higher incidence of bleeding has been reported in patients, particularly women, over 60 years of age

The use of toradol (ketorolac) with heparin may increase the risk of bleeding.

• Key points to consider:
  • Concurrent use of ketorolac and heparin may increase the risk of bleeding
  • Patients on therapeutic doses of anticoagulants, such as heparin, have an increased risk of bleeding complications if given ketorolac concurrently
  • Hemorrhage can occur at virtually any site in patients receiving heparin
  • A higher incidence of bleeding has been reported in patients, particularly women, over 60 years of age 2 3

From the Research

Heparin and Toradol Interaction

• The interaction between heparin and toradol (ketorolac) has been studied in various clinical settings 4.
• A study published in 1999 found that the administration of ketorolac significantly prolonged the skin bleeding time, and there was a significant interaction between ketorolac and dalteparin (a low-molecular-weight heparin) to prolong the bleeding time 4.
• Another study published in 2013 found that coadministration of heparin with NSAIDs, including ketorolac, was associated with an increased risk of adverse drug reactions, including bleeding complications 5.

Bleeding Risk with Heparin and Toradol

• The use of heparin and toradol together may increase the risk of bleeding complications, particularly in patients with relative contraindications or those receiving long-term treatment 5.
• A study published in 2008 found that patients receiving heparin should be monitored for platelet count and thrombotic events, especially if they have a history of heparin-induced thrombocytopenia (HIT) 6.
• The management of patients with HIT who require anticoagulant therapy is complex, and the use of alternative anticoagulant agents, such as direct thrombin inhibitors and anti-Xa agents, is preferable 7.

Clinical Implications

• The findings of these studies suggest that clinicians should exercise caution when coadministering heparin and toradol, particularly in patients at high risk of bleeding complications 5, 4.
• Further studies are needed to examine the clinical importance of the interaction between heparin and toradol and to determine the safest and most effective treatment strategies for patients requiring anticoagulant therapy 4, 7.