Most Potent NSAID for Adults
Ketorolac is the most potent NSAID available, with analgesic potency comparable to morphine and significantly greater than ibuprofen or other conventional NSAIDs. 1, 2
Potency Comparison
- Ketorolac demonstrates analgesic effects equivalent to opioids like morphine for many types of pain, making it substantially more potent than standard NSAIDs such as ibuprofen or naproxen 1, 2
- Among oral NSAIDs, indomethacin has the highest anti-inflammatory activity at full doses, but this correlates with increased ulcerogenic potential 3
- Ibuprofen at low doses (≤1200 mg/day) is less ulcerogenic than other NSAIDs, but when used at full anti-inflammatory doses (≥2400 mg/day), its GI bleeding risk becomes comparable to other NSAIDs 3, 4
Recommended Dosing for Ketorolac
Parenteral Administration
- Intravenous route: 0.5 mg/kg initial dose, followed by 1.0 mg/kg every 6 hours (maximum 90 mg/day) 2
- Maximum duration: 48 hours for parenteral therapy 2
- Intramuscular injections are not preferred unless IV access is unavailable 2
Oral Administration
Critical Safety Considerations
Absolute Contraindications
- Active peptic ulcer disease or history of GI bleeding 3
- Severe renal impairment (CrCl <10 mL/min) 5
- Recent coronary artery bypass graft surgery 6
- Bleeding disorders or concurrent anticoagulation (increases GI bleeding risk 3-6 fold) 4, 7
High-Risk Populations Requiring Avoidance
- Age ≥75 years: 1 in 110 annual risk of serious GI bleeding 6, 4
- Heart failure patients: NSAIDs cause fluid retention and worsen cardiac function 3, 6
- Uncontrolled hypertension: NSAIDs increase blood pressure by mean of 5 mmHg 6, 7
- History of cardiovascular disease: COX-2 inhibitors and NSAIDs increase MI and stroke risk 3, 7, 8
Safer Alternatives for Standard Pain Management
First-Line Approach
- Acetaminophen up to 3000 mg daily is the preferred first-line agent for mild-to-moderate pain in adults without contraindications 3, 6, 5
- Ibuprofen 400-800 mg every 6 hours (maximum 2400 mg/day) represents a reasonable balance of efficacy and safety for short-term use (≤5-10 days) 6
Duration Limits
- Acute pain: 5-10 days maximum for any NSAID 6
- Chronic pain requiring NSAIDs beyond 2 weeks mandates monitoring every 3 months (blood pressure, renal function, liver enzymes, CBC, fecal occult blood) 6, 5
Risk Mitigation Strategies
Gastroprotection
- All patients with history of peptic ulcer disease require proton pump inhibitor co-therapy, which reduces upper GI bleeding risk by 75-85% 5, 4, 7
- COX-2 selective inhibitors (celecoxib) plus PPI for highest-risk patients 3, 7
Cardiovascular Protection
- For patients requiring NSAIDs with cardiovascular risk factors, naproxen or celecoxib are preferred agents 7
- Avoid ibuprofen in patients taking low-dose aspirin for cardioprotection, as ibuprofen interferes with aspirin's antiplatelet effect 3, 5
Monitoring Requirements
- Discontinue immediately if: BUN/creatinine doubles, hypertension develops or worsens, liver enzymes exceed normal limits, or any signs of GI bleeding occur 6
Common Pitfalls to Avoid
- Do not combine multiple NSAIDs simultaneously—this increases risk without additional benefit 5
- Account for "hidden sources" of NSAIDs in combination products (e.g., cold medications, menstrual products) 3, 5
- Ketorolac's slower onset compared to morphine requires anticipatory dosing for optimal pain control 1
- Never exceed 48 hours of parenteral ketorolac or 7 days of oral therapy due to cumulative toxicity risk 2