What is the recommended dose of ketorolac (NSAID) IV for a patient with a gastric ulcer requiring pain management, considering their risk for gastrointestinal complications and potential renal impairment?

Ketorolac IV Dosing

In a patient with a gastric ulcer, ketorolac is absolutely contraindicated and should not be administered at any dose. 1

Absolute Contraindication in This Patient

• Ketorolac is contraindicated in patients with active peptic ulcer disease, history of peptic ulcer disease, or recent gastrointestinal bleeding because it can cause peptic ulcers, gastrointestinal bleeding, and perforation of the stomach or intestines, which can be fatal. 1

• These events can occur at any time during use and without warning symptoms, making ketorolac particularly dangerous in patients with pre-existing gastric ulcers. 1

• Elderly patients are at even greater risk for serious gastrointestinal events, and case reports document fatal gastric ulcer perforations in elderly patients receiving ketorolac. 1, 2

Alternative Analgesic Strategies

Opioid analgesics are the safe and effective alternative for this patient, as they do not carry the gastrointestinal risks associated with NSAIDs. 3

• Acetaminophen 650 mg every 4-6 hours (maximum 3-4 grams daily) provides analgesia without gastrointestinal, renal, or platelet effects and should be considered as first-line therapy. 3

• If opioids are needed, they can be combined with acetaminophen for synergistic pain relief without overlapping toxicity profiles. 4

Standard Ketorolac Dosing (For Appropriate Candidates Only)

For patients WITHOUT contraindications, the FDA-approved dosing is: 1

Multiple-Dose Regimen (IV or IM)

• Patients <65 years: 30 mg IV every 6 hours (maximum 120 mg/day) 1
• Patients ≥65 years, renally impaired, or <50 kg: 15 mg IV every 6 hours (maximum 60 mg/day) 1

Single-Dose Regimen

• Patients <65 years: 30 mg IV as single dose 1
• Patients ≥65 years, renally impaired, or <50 kg: 15 mg IV as single dose 1

Critical Administration Details

• IV bolus must be given over no less than 15 seconds 1
• Maximum duration of therapy is 5 days for all patients 1
• Analgesic effect begins in approximately 30 minutes with maximum effect at 1-2 hours 1

Additional High-Risk Contraindications

Beyond gastric ulcer, ketorolac is contraindicated in: 1

• Renal impairment: Advanced renal impairment or patients at risk for renal failure due to volume depletion 1
• Bleeding risk: Suspected or confirmed cerebrovascular bleeding, hemorrhagic diathesis, incomplete hemostasis, or high risk of bleeding 1
• Cardiovascular: Coronary artery bypass graft (CABG) surgery setting 1
• Concurrent NSAIDs: Patients currently receiving aspirin or other NSAIDs due to cumulative toxicity risk 1

Monitoring Requirements (If Ketorolac Were Appropriate)

• Baseline assessment: blood pressure, BUN, creatinine, liver function tests, CBC, and fecal occult blood 3
• Discontinue immediately if: BUN or creatinine doubles, hypertension develops or worsens, liver function tests increase >3 times upper limit of normal, or gastrointestinal bleeding occurs 3

Clinical Pitfall to Avoid

The most critical error would be administering ketorolac to this patient despite the gastric ulcer history. The FDA black box warning explicitly states this is contraindicated because gastrointestinal bleeding and perforation can be fatal and occur without warning. 1 Case reports document deaths from perforated gastric ulcers in elderly patients receiving ketorolac, even at recommended doses. 2