Is ketorolac appropriate for treating diarrhea and abdominal pain in an adult (including older adults) with or without comorbidities?

Ketorolac is NOT Appropriate for Treating Diarrhea and Abdominal Pain

Ketorolac should be avoided in patients with diarrhea and abdominal pain, as NSAIDs like ketorolac are actually listed as a cause of diarrhea and can worsen gastrointestinal symptoms, increase bleeding risk, and potentially mask serious underlying conditions. 1

Why Ketorolac is Contraindicated

NSAIDs Cause Diarrhea

• NSAIDs, including ketorolac, are recognized as a medication-induced cause of diarrhea in patients with advanced disease and should be discontinued rather than initiated 1
• When evaluating diarrhea in adults, medication adjustment is the primary management strategy when NSAIDs are identified as the culprit 1

Serious Gastrointestinal Risks

• Ketorolac carries significant risk of gastrointestinal bleeding, perforation, and peptic ulcer formation, particularly in vulnerable populations 2, 3
• In elderly patients, ketorolac has been associated with perforated gastric ulcers, with fatal outcomes reported after as few as 9-16 doses 2
• The risk increases markedly with high dosages used for more than 5 days, especially in elderly patients 4, 3
• Gastric ulcer perforation has been documented even in younger patients receiving multiple doses over weeks 5

Masking Serious Pathology

• In patients with abdominal pain and diarrhea, serious conditions like neutropenic enterocolitis, ischemic colitis, or infectious colitis must be excluded 1
• Using ketorolac for pain control could mask evolving peritonitis, perforation, or other surgical emergencies that require urgent intervention 1

Appropriate Management Instead

For Uncomplicated Diarrhea with Abdominal Pain

• Start loperamide 4 mg initially, followed by 2 mg every 4 hours or after every unformed stool (maximum 16 mg/day) 1, 6
• Implement oral hydration and dietary modifications (eliminate lactose, spices, coffee, alcohol, high-osmolar supplements) 1, 6
• Monitor for signs of complicated diarrhea requiring escalation of care 1

For Complicated Diarrhea (with fever, dehydration, bleeding, or severe symptoms)

• Hospitalize and provide IV fluids and electrolytes 1, 7
• Consider broad-spectrum antibiotics (fluoroquinolones or metronidazole) if infectious etiology suspected 1
• Octreotide 100-150 μg subcutaneously three times daily may be needed for severe cases 1, 7
• Obtain stool evaluation for blood, C. difficile, Salmonella, E. coli, and Campylobacter 1

Pain Management Alternatives

• If analgesia is needed, acetaminophen is safer than NSAIDs in the context of gastrointestinal symptoms 4
• For severe pain requiring stronger analgesia, opioids may be considered in non-neutropenic patients without ileus, though they should be used cautiously as they can worsen constipation 1

Critical Pitfalls to Avoid

• Never use ketorolac in patients with active or suspected gastrointestinal pathology 3
• Do not use ketorolac in elderly patients without careful risk assessment, as they have markedly increased risk of serious complications 2, 3
• Avoid all anticholinergic, antidiarrheal, and opioid agents in neutropenic enterocolitis as they may aggravate ileus 6
• Do not use loperamide in bloody diarrhea or suspected dysentery without appropriate antibiotic coverage 6

The combination of diarrhea and abdominal pain requires diagnostic evaluation, not symptomatic pain control with an NSAID that could worsen the underlying condition. 1