Ketorolac (Toradol) Dosing for Acute Pain
For adults aged 17-64 years, administer ketorolac 15-30 mg IV/IM every 6 hours (maximum 120 mg/day) for no more than 5 days total duration, transitioning to oral ketorolac 20 mg once followed by 10 mg every 4-6 hours as needed (maximum 40 mg/day oral) if IV/IM therapy was initiated first. 1, 2
Adult Dosing (Ages 17-64 Years)
Parenteral Administration
- Initial dose: 15-30 mg IV or IM every 6 hours 1
- Maximum daily dose: 120 mg 1
- Maximum duration: 5 days total (combined IV/IM and oral) 1, 2
Oral Administration (Continuation Therapy Only)
- Transition dose: 20 mg PO once, then 10 mg every 4-6 hours as needed 2
- Maximum daily dose: 40 mg 2
- Important: Oral ketorolac should NOT be used as initial therapy—it is only indicated as continuation after IV/IM dosing 2
- Minimum dosing interval: Do not shorten the 4-6 hour interval 2
High-Risk Populations Requiring Dose Reduction
Elderly Patients (≥65 Years)
- Reduced dose: 15 mg IV/IM every 6 hours (not 30 mg) 1
- Oral transition: 10 mg PO once, then 10 mg every 4-6 hours (maximum 40 mg/day) 2
- Rationale: Elderly patients have decreased baroreceptor sensitivity and increased risk of acute kidney injury, GI bleeding, and cardiovascular events 3
Patients with Renal Impairment
- Reduced dose: 15 mg IV/IM every 6 hours 1
- Oral transition: 10 mg PO once, then 10 mg every 4-6 hours (maximum 40 mg/day) 2
- Extreme caution required: Monitor BUN and creatinine closely; discontinue if values double 3
Low Body Weight (<50 kg or 110 lbs)
- Reduced dose: 15 mg IV/IM every 6 hours 1
- Oral transition: 10 mg PO once, then 10 mg every 4-6 hours (maximum 40 mg/day) 2
Pediatric Dosing
Children (Age ≥1 Year)
- IV dose: 0.5 mg/kg initial dose, followed by 1.0 mg/kg every 6 hours OR continuous infusion of 0.17 mg/kg/hour 4
- Maximum daily dose: 90 mg 4
- Maximum duration: 48 hours for IV/IM 4
- Oral dose: 0.25 mg/kg up to maximum 1.0 mg/kg/day for maximum 7 days 4
- Not recommended: Infants <1 year of age 4
- Note: Higher relative dosing required in children due to increased volume of distribution and plasma clearance compared to adults 4
Route Selection in Children
- Preferred: Intravenous route during immediate postoperative period 4
- Avoid: Intramuscular injections unless IV route unavailable 4
Absolute Contraindications
Do not administer ketorolac in the following situations:
- Active or history of peptic ulcer disease or GI bleeding 1, 3
- Aspirin or NSAID-induced asthma 1, 3
- Cerebrovascular hemorrhage or active bleeding 1, 3
- Advanced renal impairment or risk of renal failure 1, 3
- Pregnancy, labor, delivery, or nursing 5
- Concurrent anticoagulant, antiplatelet, SSRI, or SNRI therapy (significantly increased bleeding risk) 3
- Thrombocytopenia 3
- History of cardiovascular disease or high cardiovascular risk 3
Relative Contraindications and Cautions
Use with Extreme Caution In:
- Patients ≥60 years of age (highest risk for GI toxicity and renal complications) 1, 3
- Compromised fluid status or volume depletion 1, 3
- Concurrent nephrotoxic drugs 1, 3
- Heart failure or hypertension 3
- Hepatic dysfunction 3
- History of significant alcohol use 3
- Patients on ACE inhibitors or diuretics (drug interactions) 3
Mandatory Monitoring Requirements
Baseline Assessment (Before Initiating Therapy)
- Blood pressure 1, 3
- BUN and creatinine 1, 3
- Liver function tests 1, 3
- Complete blood count 1, 3
- Fecal occult blood 1, 3
Ongoing Monitoring
- Repeat all baseline tests every 3 months if long-term therapy required 1
- Discontinue immediately if: 3
- Liver function tests increase
- BUN or creatinine doubles
- Hypertension develops or worsens
- Unexplained dyspnea or edema suggesting heart failure occurs
Special Clinical Situations
Post-Cesarean Delivery Pain
- Recommended regimen: 30 mg IV at end of surgery, then 30 mg IV every 6 hours for 24 hours, followed by transition to oral ibuprofen 600 mg every 6 hours 1
- Maximum duration: 5 days 1
- Breastfeeding: Not a contraindication when used as directed in immediate postpartum period 1
ICU Procedural Pain
- Single dose: 30 mg IV for procedures such as chest tube removal (comparable efficacy to morphine 4 mg IV) 1
Spine Surgery
- Short-term use (<2 weeks): Safe and effective with superior functional pain scores compared to opioids, no increased pseudarthrosis risk or postoperative hematoma 1
Common Adverse Effects
- Edema 1
- Drowsiness and dizziness 1
- Gastrointestinal upset 1
- Increased diaphoresis 1
- Mean blood pressure increase of approximately 5 mm Hg 3
Critical Safety Considerations
Maximum Duration Rule
Never exceed 5 days total duration of ketorolac therapy (combined IV/IM and oral). 1, 2, 5 Risk of serious adverse events increases markedly with prolonged therapy, especially GI bleeding and renal failure 5, 6
Onset of Analgesia
- Limitation: Prolonged onset to analgesic action (30-60 minutes) 7
- Clinical implication: More than 25% of patients may exhibit little or no response 7
- Strategy: Consider combining with opioids for synergistic effect and 25-50% opioid dose reduction 6
Gastroprotection
- High-risk patients: Co-prescribe proton pump inhibitor when ketorolac must be used despite GI bleeding concerns 3