Can Toradol (ketorolac) be administered after giving 324 mg of chewable aspirin (acetylsalicylic acid) in the emergency department?

From the Guidelines

It is not recommended to administer Toradol (ketorolac) to a patient who has recently received aspirin (324 mg) in the emergency department. Both medications are non-steroidal anti-inflammatory drugs (NSAIDs) that work through similar mechanisms by inhibiting cyclooxygenase enzymes. Combining these medications increases the risk of adverse effects, particularly gastrointestinal bleeding, without providing significant additional pain relief 1. The combination can also increase the risk of renal impairment and may enhance antiplatelet effects, potentially increasing bleeding risk.

Key Considerations

• The use of NSAIDs, except for aspirin, should be avoided in patients with acute coronary syndromes due to increased risks of mortality, reinfarction, hypertension, heart failure, and myocardial rupture 1.
• If additional pain management is needed after aspirin administration, consider alternative analgesics from different drug classes such as acetaminophen or, if appropriate, opioid medications.
• Always evaluate the patient's complete medication history, kidney function, and risk factors for GI bleeding before administering any NSAID.
• If Toradol is deemed necessary despite recent aspirin use, implement appropriate gastroprotective strategies such as proton pump inhibitors and use the lowest effective dose for the shortest duration possible 1.

Alternative Options

• Acetaminophen can be considered as an alternative analgesic for pain management.
• Opioid medications may be used if appropriate, but with caution due to potential risks of dependency and respiratory depression.
• The patient's condition and response to treatment should be closely monitored, and adjustments made as necessary to minimize risks and optimize outcomes.

From the FDA Drug Label

Ketorolac tromethamine is contraindicated in patients currently receiving aspirin or NSAIDs because of the cumulative risks of inducing serious NSAID-related adverse events.

The patient has been given 324 mg of chewable aspirin, which is an NSAID. Ketorolac (Toradol) should not be given to this patient due to the risk of cumulative adverse effects.

• The use of ketorolac tromethamine with aspirin or other NSAIDs is contraindicated 2.
• Concomitant administration of ketorolac tromethamine and aspirin is not generally recommended because of the potential of increased adverse effects 2.

From the Research

Administration of Toradol after Aspirin

• The administration of Toradol (ketorolac) after giving someone 324 mg of chewable aspirin in the emergency department is a concern due to the potential interaction between the two medications 3.
• Studies have shown that non-selective non-steroidal anti-inflammatory drugs (NSAIDs) like ketorolac can interfere with the antiplatelet effect of aspirin through competitive binding with COX-1 3.
• However, the clinical significance of this interaction is still unclear, and the decision to administer Toradol after aspirin should be made on a patient-by-patient basis, taking into account factors such as dose timing, dose of aspirin, and dose of the NSAID in question 3.

Pharmacokinetics of Aspirin Formulations

• A study comparing three aspirin formulations found that chewable aspirin achieved the most rapid rate of absorption, with measurable salicylate concentrations seen in all subjects at 45 minutes 4.
• The same study found that the chewable formulation had a more complete absorption than the other formulations at 180 minutes 4.
• Another study found that soluble aspirin is faster than whole solid aspirin, which is faster than enteric-coated aspirin in achieving platelet inhibition 5.

Efficacy of Ketorolac and Aspirin

• A study evaluating the efficacy of ketorolac, aspirin, and an acetaminophen-codeine combination in postoperative oral surgery pain found that ketorolac was significantly superior to aspirin for every measure of total and peak analgesia 6.
• Another study found that the combination of paracetamol and an NSAID (including ketorolac) was more effective than paracetamol or NSAID alone in 85% and 64% of relevant studies, respectively 7.