Can a patient with ankylosing spondylitis, currently taking Mobic (meloxicam) and sulfasalazine, receive a Toradol (ketorolac) injection for pain management?

Can Toradol (Ketorolac) Injection Be Given to a Patient with Ankylosing Spondylitis Taking Mobic and Sulfasalazine?

No, you should not administer a Toradol (ketorolac) injection to this patient because they are already taking Mobic (meloxicam), and combining two NSAIDs significantly increases the risk of serious gastrointestinal bleeding, renal toxicity, and cardiovascular events without providing additional therapeutic benefit.

Critical Drug Safety Concern

The primary issue here is concurrent NSAID use, not the ankylosing spondylitis diagnosis or sulfasalazine therapy:

• Ketorolac and meloxicam are both NSAIDs, and the FDA label for ketorolac explicitly warns that "concomitant administration of ketorolac tromethamine and aspirin is not generally recommended because of the potential of increased adverse effects," a principle that extends to all NSAIDs 1
• The risk of GI bleeding is synergistic when multiple NSAIDs are combined, meaning the combined risk exceeds the sum of individual risks 1
• Ketorolac carries a boxed warning for GI ulceration, bleeding, and perforation, with adverse reaction rates that increase with higher doses and concurrent NSAID use 1

Why This Combination Is Dangerous

Gastrointestinal Toxicity

• The FDA label states that ketorolac can cause "serious GI tract ulcerations and bleeding without warning symptoms" 1
• A large postmarketing study of approximately 10,000 patients demonstrated dose-dependent risk of clinically serious GI bleeding with ketorolac, particularly in elderly patients receiving average daily doses greater than 60 mg/day 1
• Adding ketorolac to existing meloxicam therapy would compound this risk without clinical justification 1

Renal Toxicity

• Both ketorolac and meloxicam inhibit renal prostaglandin synthesis, which can reduce natriuretic effects and precipitate acute renal failure 1
• The FDA label warns that ketorolac "can reduce the natriuretic effect of furosemide and thiazides" through prostaglandin inhibition, and concurrent NSAIDs increase risk of renal failure 1

No Additional Therapeutic Benefit

• NSAIDs work through the same mechanism (COX inhibition), so adding ketorolac provides no additional anti-inflammatory benefit beyond what meloxicam already provides 2
• ASAS/EULAR guidelines recommend NSAIDs as first-line treatment for AS but do not support combining multiple NSAIDs 2

Sulfasalazine Is Not a Contraindication

The sulfasalazine therapy is irrelevant to the decision about ketorolac:

• Sulfasalazine has no significant drug interactions with NSAIDs that would preclude ketorolac use 2
• The main concern with sulfasalazine is its common but usually mild toxicity (GI symptoms, mucocutaneous manifestations, hepatic enzyme abnormalities), not NSAID interactions 2
• Sulfasalazine is used in AS primarily for peripheral arthritis, not axial disease, and patients typically continue NSAIDs concurrently 2, 3

Alternative Pain Management Strategies

If the patient requires additional pain control beyond their current meloxicam regimen:

Option 1: Optimize Current NSAID Therapy

• Increase meloxicam dose to the maximum recommended (15 mg daily for AS) if not already at that level 2
• Switch to continuous NSAID dosing rather than on-demand if the patient has persistently active disease 3
• Consider timing the dose before bedtime if night pain and morning stiffness are predominant symptoms 4

Option 2: Add Non-NSAID Analgesics

• Acetaminophen (paracetamol) can be added for additional pain control without the risks of dual NSAID therapy 2
• ASAS/EULAR guidelines state that "analgesics, such as paracetamol and opioids, might be considered for pain control in patients in whom NSAIDs are insufficient, contraindicated, and/or poorly tolerated" 2
• Short-term opioids may be considered for severe breakthrough pain, though this is not a long-term solution 2

Option 3: Local Corticosteroid Injections

• Intra-articular or periarticular corticosteroid injections are appropriate for localized musculoskeletal inflammation in AS 2
• ASAS/EULAR guidelines provide level Ib evidence that corticosteroid injections are effective for sacroiliitis pain 2
• This approach targets specific sites of inflammation without systemic NSAID toxicity 2

Option 4: Escalate to Biologic Therapy

• If the patient has persistently high disease activity despite optimal NSAID therapy, biologic DMARDs (TNF inhibitors or IL-17 inhibitors) are strongly recommended 3, 5
• The American College of Rheumatology recommends biologics for patients with active AS despite NSAIDs, not adding more NSAIDs 3

Common Pitfalls to Avoid

• Do not assume that injectable NSAIDs are "different" from oral NSAIDs – they share the same mechanism and toxicity profile 1
• Do not use ketorolac for chronic pain management – it is FDA-approved only for short-term use (≤5 days) due to serious adverse effects 1
• Do not combine NSAIDs without compelling justification – the risks always outweigh any theoretical benefits 1
• Do not overlook that sulfasalazine provides minimal benefit for axial AS symptoms – if pain is inadequately controlled, the issue is likely insufficient NSAID therapy or need for biologic escalation, not sulfasalazine failure 3, 6, 7