What is Toradol (ketorolac)?

What is Toradol (Ketorolac)?

Toradol (ketorolac tromethamine) is a potent nonsteroidal anti-inflammatory drug (NSAID) with strong analgesic properties, providing opioid-level pain relief for moderate to severe acute pain without the risks of respiratory depression, sedation, euphoria, or addiction that characterize opioid medications. 1, 2

Mechanism of Action and Pharmacology

• Ketorolac works by reversibly inhibiting cyclooxygenase (COX) enzymes, which reduces prostaglandin synthesis and thereby decreases pain and inflammation 2, 3
• The drug is a racemic mixture of S- and R-enantiomers, with the S-form providing the analgesic activity 3
• Peak analgesic effect occurs within 2-3 hours after administration, with the S-enantiomer cleared approximately twice as fast as the R-enantiomer 3
• Ketorolac is 99% protein-bound and has a mean apparent volume of distribution of approximately 13 liters in adults 3

Available Formulations and Routes

• Ketorolac is available in multiple formulations: intravenous (IV), intramuscular (IM), oral tablets, and topical ophthalmic solution 3, 4
• Oral ketorolac has 100% bioavailability and is equally bioavailable to IM administration 3
• Each oral tablet contains 10 mg ketorolac tromethamine as the active ingredient 3

Clinical Applications and Efficacy

• Postoperative pain: Ketorolac provides analgesia comparable to standard doses of morphine and meperidine (pethidine) after major abdominal, orthopedic, or gynecological surgery 4
• Emergency department use: Effective for moderate to severe pain from renal colic, migraine headache, musculoskeletal pain, and sickle cell crisis 4
• Pediatric use: In children undergoing myringotomy, hernia repair, or tonsillectomy, ketorolac provides comparable analgesia to morphine, pethidine, or acetaminophen 4, 5
• Opioid-sparing effect: When combined with opioids, ketorolac reduces opioid requirements by 25-50%, which decreases opioid-related adverse events including respiratory depression, nausea, vomiting, and ileus 2, 4

Standard Dosing Recommendations

• Adults (age 17-64 years): 15-30 mg IV/IM every 6 hours, with a maximum daily dose of 120 mg 1
• Elderly patients (≥60 years): Use lower doses of 15 mg IV/IM every 6 hours due to increased risk of adverse effects 1
• Pediatric patients: 0.5 mg/kg IV bolus, followed by 1.0 mg/kg every 6 hours or 0.17 mg/kg/hour infusion (maximum 90 mg/day) 5
• Maximum treatment duration: 5 days for all routes of administration 1, 2

Key Advantages Over Opioids

• No addiction potential: Ketorolac provides opioid-level analgesia without triggering dopamine release in the nucleus accumbens, eliminating the risk of euphoria, dependence, or withdrawal symptoms 2
• No respiratory depression: Unlike opioids, ketorolac does not depress ventilation 2, 5
• Safe in substance abuse history: Patients with a history of substance abuse can safely receive ketorolac without triggering relapse or developing new substance use disorders 2
• No withdrawal syndrome: Ketorolac can be stopped abruptly without any withdrawal symptoms 2

Critical Contraindications

• Absolute contraindications: Aspirin/NSAID-induced asthma, pregnancy, cerebrovascular hemorrhage, active peptic ulcer disease, or active GI bleeding 1
• Avoid concurrent use: Do not combine with other NSAIDs (including ibuprofen) due to additive toxicity without additional analgesic benefit 6
• High-risk populations requiring caution: Age ≥60 years, compromised fluid status, renal impairment, concurrent nephrotoxic drugs, history of cardiovascular disease, or concurrent anticoagulation 1, 6

Common Adverse Effects

• Gastrointestinal: Edema, GI upset, and risk of ulceration and bleeding (even with parenteral administration) 1, 7
• Renal: Acute kidney injury, particularly in patients with marginal kidney function 2
• Hematologic: Reversible inhibition of platelet aggregation and increased bleeding time 7, 5
• Other: Drowsiness, dizziness, and increased diaphoresis 1

Monitoring Requirements

• Baseline assessment: Blood pressure, BUN, creatinine, liver function tests, CBC, and fecal occult blood 1
• For long-term therapy: Repeat monitoring every 3 months 1
• Discontinuation criteria: BUN or creatinine doubles, hypertension develops or worsens, liver function tests increase >3 times upper limit of normal, or GI bleeding occurs 6

Important Clinical Pearls

• The risk of serious adverse events increases markedly when high dosages are used for more than 5 days, especially in the elderly 4
• Ketorolac has a delayed onset of action (30-60 minutes IM) compared to opioids, but often provides longer-lasting analgesia 4, 8
• When switching from ibuprofen to ketorolac, wait 6-8 hours after the last ibuprofen dose to avoid NSAID stacking and additive toxicity 6
• Ketorolac can be safely alternated with acetaminophen (650 mg every 4-6 hours) for enhanced pain control, as these medications have non-overlapping toxicity profiles 6