Management of Acid Reflux After Single Toradol Injection
Discontinue ketorolac immediately and initiate a proton pump inhibitor (PPI) at standard once-daily dosing for 4-8 weeks to treat the NSAID-induced reflux symptoms. 1, 2
Immediate Actions
Stop ketorolac permanently – The FDA label explicitly warns that ketorolac can cause serious GI side effects including ulcers and bleeding, and patients should be alert for epigastric pain and dyspepsia, which are your presenting symptoms. 2
Start PPI therapy immediately – Begin a standard-dose PPI (such as omeprazole 20 mg, pantoprazole 40 mg, or esomeprazole 40 mg) taken 30-60 minutes before breakfast for optimal acid suppression. 1, 3
Duration of PPI treatment – Continue for 4-8 weeks, which is the recommended trial period for reflux symptoms and allows adequate time for healing of any NSAID-induced mucosal injury. 1
Symptomatic Management During PPI Therapy
Add alginate-based antacids for breakthrough symptoms while the PPI takes full effect (typically 3-5 days). Alginates form a physical barrier over gastric contents and are specifically recommended for breakthrough reflux symptoms. 1, 4
Avoid additional NSAIDs – Do not use ibuprofen, naproxen, aspirin (except low-dose cardioprotective aspirin if prescribed), or any other NSAIDs, as these will perpetuate the gastric irritation. 5, 2
Lifestyle Modifications
Weight management and dietary changes – Avoid large meals, late-night eating, and known trigger foods (caffeine, alcohol, chocolate, fatty foods, citrus, tomatoes). 1
Elevate head of bed 30-45 degrees to reduce gravitational reflux, particularly at night. 4
Follow-Up Strategy
Reassess at 4 weeks – If symptoms resolve completely, attempt to taper the PPI to the lowest effective dose or discontinue after 8 weeks total. 1
If symptoms persist beyond 4-8 weeks on PPI – Perform upper endoscopy to evaluate for erosive esophagitis, ulceration, or other pathology, especially given the recent NSAID exposure. 1
Red flag symptoms requiring immediate evaluation – Seek urgent care if you develop severe abdominal pain, vomiting blood, black tarry stools, difficulty swallowing, or unexplained weight loss, as these may indicate GI bleeding or perforation from the ketorolac. 2, 6
Future Pain Management
Avoid ketorolac permanently – You have demonstrated susceptibility to NSAID-induced GI complications. 5, 2
Alternative analgesics – Use acetaminophen as first-line for pain management (up to 3000-4000 mg daily in divided doses if no liver disease). If NSAIDs are absolutely necessary in the future, use the lowest effective dose of ibuprofen (≤1200 mg/day) for the shortest duration (<7 days) with mandatory PPI co-therapy. 5
Key Clinical Pearls
The FDA label for ketorolac specifically warns that serious GI ulcerations and bleeding can occur without warning symptoms, but patients should be alert for epigastric pain and dyspepsia – exactly what you experienced. 2 Even a single dose can trigger these effects in susceptible individuals. 6 The American Gastroenterological Association emphasizes that PPIs are the most effective agents for healing NSAID-associated ulcers and preventing complications. 5 Your symptoms after just one injection indicate you are at high risk for NSAID complications and should avoid this entire drug class whenever possible.