What is the appropriate outpatient prescription for ketorolac (Toradol) in an adult with short‑term moderate‑to‑severe pain, including dose, maximum daily amount, duration, contraindications, and alternative analgesics?

Outpatient Ketorolac Prescription Guidelines

Ketorolac should only be prescribed for outpatient use as a continuation of parenteral therapy initiated in a clinical setting, with a maximum total combined duration of 5 days and strict adherence to reduced dosing for elderly or high-risk patients. 1

Critical Prescribing Restrictions

Ketorolac tablets are FDA-approved only as continuation therapy after initial IV/IM dosing—never as first-line outpatient treatment. 1 The drug must be initiated with parenteral administration in a supervised setting before transitioning to oral therapy. 1

Maximum Duration and Dosing

• Total combined duration (IV/IM + oral) must not exceed 5 days due to dose-dependent serious adverse events, particularly GI bleeding. 1
• For adults 17-64 years: 10 mg orally every 4-6 hours as needed, maximum 40 mg/day. 2
• For adults ≥65 years, weight <50 kg, or renal impairment: Reduce dose to 15 mg every 6 hours (maximum 60 mg/day) for parenteral dosing; oral dosing should be similarly reduced. 3, 1

Absolute Contraindications

Ketorolac is contraindicated in patients with: 2, 3, 1

• Active or history of peptic ulcer disease or GI bleeding
• Aspirin/NSAID-induced asthma or hypersensitivity
• Advanced renal impairment or risk of renal failure
• Cerebrovascular bleeding or high cardiovascular risk
• Concurrent anticoagulant/antiplatelet therapy or bleeding disorders
• Pregnancy or breastfeeding
• Age >60 years with significant alcohol use or hepatic dysfunction

Required Baseline Monitoring

Before prescribing ketorolac, obtain: 3, 4

• Blood pressure
• BUN and creatinine
• Liver function tests
• Complete blood count
• Fecal occult blood test (if GI risk factors present)

Immediate Discontinuation Criteria

Stop ketorolac immediately if: 3, 4

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

Superior First-Line Alternatives

Standard NSAIDs like ibuprofen 600-800 mg every 6 hours (maximum 2400 mg/day) have significantly better safety profiles for outpatient use and should be prescribed instead of ketorolac for most acute pain. 2, 3 Ibuprofen provides comparable analgesia without the severe restrictions and monitoring requirements of ketorolac. 2

For Neuropathic Pain Components

Add coanalgesics rather than relying solely on NSAIDs: 3, 4

• Gabapentin: Start 100-300 mg at bedtime, titrate to 900-3600 mg/day in divided doses
• Pregabalin: Start 50 mg three times daily, increase to 100 mg three times daily
• Nortriptyline: Start 10-25 mg nightly, increase to 50-150 mg as tolerated

For Opioid-Requiring Pain

If pain severity necessitates opioid-level analgesia: 2

• Oxycodone 5-10 mg every 4-6 hours as needed for short-term use
• Hydromorphone or oxycodone are preferred over codeine combinations for moderate-severe pain 2

Critical Safety Warning

Never combine ketorolac with other NSAIDs (including ibuprofen, naproxen, or aspirin)—toxicities are additive without additional analgesic benefit, dramatically increasing risks of GI bleeding, renal failure, and cardiovascular events. 3

Dose-Dependent Bleeding Risk

A large postmarketing study demonstrated that elderly patients receiving >60 mg/day had GI bleeding rates of 7.7% without prior ulcer history and 25% with prior ulcer history, compared to 1.2% and 4.7% respectively at ≤60 mg/day. 1 This underscores the critical importance of dose reduction in vulnerable populations.

Practical Outpatient Prescription

When continuation oral therapy is appropriate after parenteral initiation:

Prescription format:

• Ketorolac 10 mg tablets
• Take 1 tablet by mouth every 4-6 hours as needed for pain
• Maximum 4 tablets in 24 hours
• Total duration including hospital doses: 5 days maximum
• Dispense: 12-20 tablets (depending on days remaining in 5-day window)
• No refills

Mandatory patient counseling: 4

• Exact dosing schedule and maximum daily dose
• Stop immediately and seek care for: black/bloody stools, severe abdominal pain, vomiting blood, decreased urine output, swelling
• Do not take with ibuprofen, naproxen, aspirin, or other NSAIDs
• Take with food to minimize GI upset
• Provide 24-hour contact number for breakthrough pain or adverse effects