Can ketorolac 10 mg intramuscularly be given to a patient with chronic obstructive pulmonary disease and a history of gastro‑oesophageal reflux disease who does not consume alcohol?

Ketorolac 10 mg IM in COPD with GERD: Safety Assessment

Ketorolac 10 mg IM can be administered to this patient, but the GERD history creates significant gastrointestinal bleeding risk that must be carefully weighed against analgesic benefit. 1

Primary Contraindication Analysis

COPD is NOT a Contraindication

• COPD itself does not contraindicate ketorolac use - the FDA label and clinical guidelines do not list COPD as a contraindication for ketorolac 1
• Unlike beta-blockers (which should be avoided in COPD with reactive airway disease), NSAIDs like ketorolac do not cause bronchospasm or worsen respiratory function in typical COPD patients 2
• Ketorolac's mechanism (COX inhibition) does not interfere with standard COPD bronchodilator therapy 2

GERD is the Critical Risk Factor

• The GERD history places this patient at higher-than-average risk for gastrointestinal bleeding, which is ketorolac's most serious adverse effect 2, 1
• The FDA black box warning explicitly states ketorolac "can cause peptic ulcers, gastrointestinal bleeding and/or perforation of the stomach or intestines, which can be fatal" 1
• Ketorolac is absolutely contraindicated in patients with active peptic ulcer disease, recent GI bleeding, or history of peptic ulcer disease/GI bleeding 1

Risk Stratification for GERD Patients

High-Risk Features (Absolute Contraindications)

If the patient has any of these, do NOT give ketorolac 1:

• Active peptic ulcer disease
• Recent gastrointestinal bleeding or perforation
• History of peptic ulcer disease or GI bleeding
• Currently taking anticoagulants
• Concurrent use of corticosteroids or other NSAIDs

Moderate-Risk Features (Relative Contraindications)

The ESC guidelines identify patients requiring proton pump inhibitors on dual antiplatelet therapy who have two or more of the following as higher risk 2:

• Age ≥65 years
• Dyspepsia
• Gastro-oesophageal reflux disease (GERD)
• Helicobacter pylori infection
• Chronic alcohol use

Your patient has GERD but no alcohol consumption, so assess for the other risk factors 2

Dosing Considerations if Administered

The 10 mg Dose is Appropriate

• 10 mg represents the analgesic ceiling dose for ketorolac - higher doses provide no additional analgesia but increase adverse effects 3
• Research demonstrates that 10 mg IV/IM ketorolac provides equivalent analgesia to 30 mg or 60 mg doses 3
• Despite this evidence, 97% of emergency physicians prescribe above the ceiling dose, which is inappropriate 3

Critical Prescribing Parameters

If you proceed with ketorolac 1, 4, 5:

• Maximum duration: 5 days total (including any oral continuation)
• Single dose: 10 mg IM (not the 30 mg or 60 mg commonly misprescribed)
• Do not use prophylactically - only for diagnosed acute pain conditions
• Do not combine with other NSAIDs, aspirin, or anticoagulants
• Monitor for GI symptoms (abdominal pain, melena, hematemesis)

Protective Strategies for GERD Patients

Mandatory Co-Prescription

• Prescribe a proton pump inhibitor (PPI) concurrently if ketorolac is deemed necessary in this GERD patient 2
• The ESC guidelines specifically recommend PPIs for patients on antiplatelet therapy with GERD or other GI risk factors 2
• This same principle applies to NSAID use in GERD patients 2

Alternative Analgesic Approaches

Consider these safer options for a COPD patient with GERD 4, 6:

• Acetaminophen (no GI bleeding risk, safe in COPD)
• Opioids (if pain severity warrants, though they carry respiratory depression risk - use cautiously in severe COPD)
• Combination therapy: Low-dose opioid + acetaminophen (opioid-sparing approach)

Clinical Decision Algorithm

Step 1: Does the patient have active peptic ulcer, recent GI bleeding, or history of peptic ulcer/GI bleeding?

• YES → Absolute contraindication, do NOT give ketorolac 1
• NO → Proceed to Step 2

Step 2: Count additional GI risk factors (age ≥65, dyspepsia, H. pylori, chronic NSAID use, anticoagulants, corticosteroids)

• ≥2 additional risk factors → High risk, strongly consider alternatives 2
• 0-1 additional risk factors → Proceed to Step 3

Step 3: Is the pain severe enough to justify GI bleeding risk?

• YES → Give ketorolac 10 mg IM ONCE with concurrent PPI, maximum 5 days total 1, 4
• NO → Use acetaminophen or other safer alternatives

Common Pitfalls to Avoid

• Do not prescribe 30 mg or 60 mg doses - these exceed the analgesic ceiling and only increase toxicity 3
• Do not use ketorolac for more than 5 days - prolonged use dramatically increases adverse event risk 1, 4
• Do not assume COPD is a contraindication - it is not, but always verify the patient isn't on anticoagulants for cor pulmonale 1
• Do not forget PPI co-prescription in GERD patients if ketorolac is necessary 2
• Do not combine with other NSAIDs or aspirin - this compounds GI bleeding risk 1, 5