Is it safe to administer a toradol (ketorolac) and steroid injection (dexamethasone) to an elderly patient with a history of atrial fibrillation (a-fib), currently in normal sinus rhythm (NSR), on diltiazem and full-strength aspirin (acetylsalicylic acid) daily, who has taken 325 mg aspirin and 400 mg ibuprofen, with a glomerular filtration rate (GFR) of 70, for back pain management?

Do Not Give This Injection

I strongly recommend against administering toradol (ketorolac) and dexamethasone injection to this patient due to multiple serious contraindications and high bleeding risk. This patient has already taken aspirin 325 mg and ibuprofen 400 mg today, creating a dangerous triple NSAID exposure that significantly increases gastrointestinal bleeding and operative site bleeding risk 1, 2.

Critical Contraindications Present

Active NSAID Exposure

• Ketorolac is absolutely contraindicated when combined with aspirin or other NSAIDs due to synergistic effects on GI bleeding risk 1
• The FDA label explicitly states that concomitant administration of ketorolac and aspirin is "not generally recommended because of the potential of increased adverse effects" 1
• Your patient has already consumed both aspirin (325 mg) and ibuprofen (400 mg) within the same day, creating triple NSAID exposure 1

Bleeding Risk Amplification

• The combination of aspirin with ketorolac creates a bleeding risk higher than either drug alone through synergistic effects on both platelet function and GI mucosa 1
• Ketorolac causes platelet inhibition with altered hemostasis, and this effect is magnified when combined with aspirin 2
• The elderly are at particularly high risk for adverse events with ketorolac, including gastrointestinal bleeding and perforation 2

Renal Function Concerns

• While her GFR of 70 is not severely impaired, ketorolac can reduce the natriuretic effect of diuretics and cause acute renal failure, which is usually reversible but concerning in elderly patients 1, 2
• The risk increases with prolonged therapy (>5 days), but even single doses carry risk in vulnerable patients like the elderly 2

Specific Drug Interaction with Diltiazem

• Diltiazem does not directly contraindicate ketorolac, but this patient's overall medication profile creates a high-risk scenario 3, 4
• The diltiazem-aspirin combination already increases bleeding risk through pharmacokinetic interactions, and adding ketorolac would compound this further 3, 4

Safe Alternative Approach

Immediate Pain Management

• Acetaminophen is the safest first-line option for this elderly patient with musculoskeletal pain, as it has less gastrointestinal toxicity than NSAIDs when maximum recommended doses are avoided 5
• Consider acetaminophen 500-650 mg every 6 hours (maximum 3000 mg/day in elderly) as it does not interact with aspirin or diltiazem 5

If Stronger Analgesia Needed

• Consider a short-acting opioid (e.g., tramadol 25-50 mg every 6 hours or low-dose oxycodone 2.5-5 mg every 6 hours) rather than ketorolac, as opioids have only slightly lower bleeding risk than ketorolac without the synergistic NSAID effects 2
• Topical NSAIDs (diclofenac gel) may be considered as they appear safe over the short term with reduced systemic adverse effects 5

Regarding the Steroid Component

• Dexamethasone 4 mg alone (without ketorolac) could be considered if you believe inflammation is a significant component, as corticosteroids do not have the same bleeding risk profile as NSAIDs
• However, given the recent fall and pending imaging, it would be prudent to wait for x-ray results before administering any injection

Critical Timing Issue

• Wait for imaging results before any injection - if she has an occult hip fracture or vertebral fracture, an injection could mask important diagnostic symptoms and delay appropriate orthopedic management 1
• Ketorolac is indicated only for short-term (≤5 days) management of moderately severe acute pain in postoperative settings, not for outpatient musculoskeletal injuries 1

Common Pitfall to Avoid

The most dangerous pitfall here is underestimating the cumulative bleeding risk from multiple antiplatelet/NSAID agents in an elderly patient. The fact that she's currently in normal sinus rhythm doesn't eliminate her baseline bleeding risk from chronic aspirin therapy, and adding ketorolac would create a multiplicative rather than additive risk 1, 2.