Will intravenous (IV) ketorolac cause a hypertensive crisis?

From the Guidelines

Intravenous (IV) ketorolac does not typically cause a hypertensive crisis. According to the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1, hypertensive emergencies are defined as severe elevations in blood pressure (>180/120 mm Hg) associated with evidence of new or worsening target organ damage. While NSAIDs like ketorolac can cause modest blood pressure elevations in some patients through inhibition of prostaglandin synthesis and subsequent sodium retention, these effects usually result in only small increases in blood pressure rather than hypertensive crisis. Some key points to consider when administering IV ketorolac include:

• The standard IV dosing is 30mg as a single dose or 15-30mg every 6 hours, not to exceed 120mg in 24 hours or use beyond 5 days due to increased risk of side effects.
• Patients with pre-existing hypertension, heart failure, or kidney disease may be more susceptible to blood pressure effects.
• The more common concerns with IV ketorolac are gastrointestinal bleeding, kidney injury, and increased risk of cardiovascular events with prolonged use.
• If you're concerned about blood pressure effects, monitoring blood pressure after administration would be prudent, especially in high-risk patients. It's essential to weigh the benefits and risks of using IV ketorolac, considering the patient's individual risk factors and medical history, as stated in the guideline 1.

From the FDA Drug Label

NSAIDs, including ketorolac tromethamine, can lead to onset of new hypertension or worsening of pre-existing hypertension, either of which may contribute to the increased incidence of CV events. Patients taking thiazides or loop diuretics may have impaired response to these therapies when taking NSAIDs NSAIDs, including ketorolac tromethamine, should be used with caution in patients with hypertension. Blood pressure (BP) should be monitored closely during the initiation of NSAID treatment and throughout the course of therapy

IV Ketorolac and Hypertensive Crisis:

• IV ketorolac may lead to onset of new hypertension or worsening of pre-existing hypertension.
• It is recommended to use IV ketorolac with caution in patients with hypertension and monitor blood pressure closely during treatment.
• However, the label does not directly state that IV ketorolac will cause a hypertensive crisis, but rather that it may contribute to the increased incidence of CV events due to its effects on blood pressure 2.

From the Research

Hypertensive Crisis and IV Ketorolac

• There is no direct evidence in the provided studies that IV ketorolac causes a hypertensive crisis 3, 4, 5, 6, 7.
• However, the studies discuss the management and treatment of hypertensive crises, including the use of intravenous antihypertensive medications such as labetalol, esmolol, fenoldopam, nicardipine, sodium nitroprusside, and clevidipine 3, 4, 5, 6.
• The studies also emphasize the importance of proper diagnosis, triage, and treatment of hypertensive crises to prevent complications and improve outcomes 3, 4, 5, 6, 7.
• It is worth noting that ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) and not typically used as an antihypertensive medication, and its use in patients with hypertension should be carefully considered due to potential effects on blood pressure and renal function 3, 4, 5, 6, 7.

Management of Hypertensive Crises

• The management of hypertensive crises involves the use of intravenous antihypertensive medications, such as those listed above, in patients with hypertensive emergencies, and oral antihypertensive medications in patients with hypertensive urgencies 3, 4, 5, 6.
• The choice of medication and the rate of blood pressure reduction depend on the severity of the hypertensive crisis, the presence of end-organ damage, and the patient's underlying medical conditions 3, 4, 5, 6, 7.
• Close monitoring of blood pressure and clinical status is essential in patients with hypertensive crises to ensure timely and effective treatment 3, 4, 5, 6, 7.

Prevention and Treatment

• Hypertensive crises are often preventable with proper management of hypertension, including lifestyle modifications and adherence to antihypertensive medication regimens 3, 4, 5, 6, 7.
• Early recognition and treatment of hypertensive crises can improve outcomes and reduce the risk of complications 3, 4, 5, 6, 7.