What are the next best steps for a patient on Toradol (ketorolac) orally with minimal pain improvement, awaiting MRI approval which may take several days?

Immediate Pain Management Strategy

Switch from oral ketorolac to intramuscular ketorolac 30 mg IM immediately, which can be repeated every 6 hours (maximum 120 mg/day) for up to 5 days total duration, while simultaneously adding gabapentin 300 mg at bedtime for neuropathic pain coverage. 1, 2, 3

Why Oral Ketorolac is Failing

• Oral ketorolac has significantly delayed onset (30-60 minutes) and more than 25% of patients exhibit little or no analgesic response 4
• The oral formulation should never be used as initial therapy—it is FDA-approved only as continuation therapy after IV/IM dosing 3
• Your patient is essentially receiving suboptimal therapy from the start 1

Immediate Next Steps

Prescribe IM ketorolac 30 mg every 6 hours (maximum 120 mg/24 hours) for patients age 17-64 years, or 15 mg every 6 hours (maximum 60 mg/24 hours) for patients ≥65 years or <50 kg. 1, 2, 3

Critical Safety Requirements Before Prescribing

Check these contraindications immediately 2, 5:

• Active or history of peptic ulcer disease or GI bleeding
• Age >60 years with significant alcohol use or hepatic dysfunction
• Renal impairment (check BUN/creatinine)
• Thrombocytopenia or concurrent anticoagulant/antiplatelet therapy
• Cardiovascular disease or high CV risk
• Dehydration or compromised fluid status

Obtain baseline labs: blood pressure, BUN, creatinine, liver function tests, CBC, and fecal occult blood before initiating IM ketorolac. 2, 5

Add Neuropathic Pain Coverage Now

While awaiting MRI, assume a neuropathic component and start adjuvant therapy 6:

Gabapentin 300 mg at bedtime, increasing to 300 mg three times daily after 2-3 days, then titrate up to 900-3600 mg/day in divided doses based on response. 2

Alternative options if gabapentin is not tolerated 6:

• Pregabalin 50 mg three times daily, increasing to 100 mg three times daily
• Nortriptyline 10-25 mg at bedtime, titrating to 50-150 mg (obtain ECG if patient >40 years old)

Duration and Transition Plan

Maximum duration of ketorolac (oral + IM combined) is 5 days total. 1, 3

Transition Strategy for Days 3-5

• Continue IM ketorolac if pain remains severe 1
• Transition to oral ibuprofen 600 mg every 6 hours (maximum 3200 mg/day) as pain improves 2
• Never combine ketorolac with other NSAIDs—toxicities are additive without additional benefit 2
• Continue gabapentin throughout and beyond the 5-day ketorolac limit 6

If Pain Persists Despite IM Ketorolac

Consider Short-Acting Opioids as Rescue

For severe pain unresponsive to IM ketorolac 6, 1:

• Add short-acting opioid (e.g., oxycodone 5-10 mg every 4-6 hours as needed)
• Ketorolac reduces opioid requirements by 25-50%, decreasing opioid-related adverse effects 1, 2
• This combination provides synergistic analgesia while minimizing opioid exposure 1

Alternative: Consider Methylprednisolone

If inflammatory component is suspected (radiculopathy, nerve root compression), consider methylprednisolone 125 mg IM once, but only if no contraindications to combining with ketorolac. 5

Critical warnings for steroid + ketorolac combination 5:

• Significantly increases GI bleeding risk, especially in patients >60 years
• Avoid in patients with peptic ulcer history, anticoagulant use, or significant alcohol use
• If used, maximum ketorolac duration remains 5 days
• Monitor closely for GI symptoms

Common Pitfalls to Avoid

1. Do not continue oral ketorolac—it was the wrong formulation from the start 3, 4
2. Do not exceed 5 days total ketorolac duration (oral + IM combined) 1, 3
3. Do not add ibuprofen or other NSAIDs while on ketorolac 2
4. Do not skip baseline labs—renal toxicity can develop rapidly 2, 5
5. Do not wait for MRI to start neuropathic pain medications if clinical suspicion exists 6

Discontinuation Criteria

Stop ketorolac immediately if 2, 5:

• BUN or creatinine doubles
• Hypertension develops or worsens
• Liver function tests increase >3× upper limit of normal
• Any signs of GI bleeding (black stools, hematemesis, severe abdominal pain)

What to Tell the Patient

Provide written instructions including 6:

• Exact dosing schedule for IM ketorolac and gabapentin
• Warning signs requiring immediate contact (GI bleeding, severe abdominal pain, decreased urine output)
• Expected timeline: IM ketorolac for maximum 5 days, gabapentin continued long-term
• Contact number for breakthrough pain or adverse effects
• Plan for MRI and follow-up within 3-5 days