Is ketorolac (Toradol) contraindicated in a 75-year-old patient with hypertension, diabetes, taking dapagliflozin (Fraxiga) and cyclobenzaprine who presents with a severe headache of 4 days duration?

Toradol (Ketorolac) Use in a 75-Year-Old with Hypertension and Diabetes

Toradol is not absolutely contraindicated in this patient, but it carries significant risks that require careful consideration and should generally be avoided in favor of safer alternatives given the patient's age, hypertension, and diabetes.

Key Risk Factors in This Patient

This 75-year-old patient has multiple characteristics that substantially increase the risk of serious adverse events from ketorolac:

• Advanced age (≥75 years) is the single most important risk factor, with elderly patients showing a 66% increased risk of gastrointestinal bleeding (OR 1.66) and 12% increased risk of operative site bleeding compared to younger patients 1
• Hypertension can be worsened by NSAIDs, which raise systolic blood pressure by an average of 5 mmHg and may compromise blood pressure control 2
• Diabetes increases baseline cardiovascular and renal risk, making NSAID-related complications more likely 3
• Concurrent dapagliflozin (Fraxiga) creates additional renal risk, as SGLT2 inhibitors can cause volume depletion that predisposes to NSAID nephrotoxicity 4

Specific Contraindications and Warnings

According to FDA labeling and clinical guidelines, ketorolac is contraindicated or should be avoided in several scenarios relevant to this patient 3, 5:

• Aspirin/NSAID-induced asthma (absolute contraindication) 3
• Cerebrovascular hemorrhage (absolute contraindication) 3
• Pregnancy and lactation (absolute contraindication) 5
• Pre-existing renal disease should prompt complete avoidance 2, 4
• Patients on anticoagulants require extreme caution or avoidance 2

Age-Related Dosing Considerations

If ketorolac must be used despite the risks, elderly patients require reduced dosing 6, 7:

• Standard elderly dosing: 15 mg IV (not 30 mg) or 30 mg IM (not 60 mg) 6
• Evidence shows no additional analgesic benefit from higher doses (30 mg IV/60 mg IM) compared to lower doses (15 mg IV/30 mg IM) in patients ≥65 years 6
• Duration must be limited to ≤5 days, as therapy beyond 5 days dramatically increases gastrointestinal bleeding risk (OR 2.20) 1
• Maximum daily dose: 60 mg in elderly patients 3

Critical Safety Monitoring

If ketorolac is administered, mandatory monitoring includes 2:

• Baseline assessment: Blood pressure, BUN, serum creatinine, liver enzymes, CBC, fecal occult blood 2
• Immediate discontinuation criteria:
  • BUN or creatinine doubles from baseline 2
  • New or worsening hypertension 2
  • Liver enzymes >3× upper limit of normal 2
  • Any evidence of gastrointestinal bleeding 2

Drug Interactions of Concern

• Cyclobenzaprine does not have significant interactions with ketorolac, but both can cause CNS depression 3
• Dapagliflozin (Fraxiga) increases risk of volume depletion and renal hypoperfusion, which predisposes to NSAID nephrotoxicity 4
• If patient is on ACE inhibitors or ARBs (not mentioned but common in hypertensive diabetics), the combination with NSAIDs dramatically increases hyperkalemia risk 2

Safer Alternative Approach

For a 4-day severe headache in this elderly patient, the following algorithm is recommended:

1. First-line: Acetaminophen 650-1000 mg every 4-6 hours (maximum 4 g/day) provides comparable analgesia without NSAID toxicities 2

2. If migraine suspected: Consider migraine-specific therapy (triptans if no cardiovascular contraindications) or combination therapy with acetaminophen, aspirin, and caffeine 3

3. If severe pain unresponsive to acetaminophen: Consider low-dose ketorolac (15 mg IV single dose) with strict monitoring, but only after:

   • Verifying adequate renal function (creatinine <1.6 mg/dL) 4
   • Confirming no history of GI bleeding or ulcer disease 7
   • Ensuring patient is not volume depleted 4

4. Adjunctive therapy: Metoclopramide 10 mg IV or prochlorperazine 25 mg can provide synergistic analgesia and treat associated nausea 3

Critical Red Flags Requiring Neuroimaging

Before administering any analgesic for a 4-day severe headache in a 75-year-old, neuroimaging should be strongly considered because 3:

• New-onset headache in an older person is a red flag for secondary causes 3
• Progressively worsening headache over 4 days suggests possible intracranial pathology 3
• If headache is worsened by Valsalva maneuver or awakens patient from sleep, imaging is mandatory 3

Common Pitfalls to Avoid

• Do not use standard adult dosing (30 mg IV/60 mg IM) in patients ≥75 years—this doubles the risk of adverse events 1, 7
• Do not combine ketorolac with other NSAIDs (including aspirin >81 mg daily) due to additive toxicity without additional benefit 2
• Do not prescribe for >5 days—prolonged therapy dramatically increases GI bleeding risk 1
• Do not assume "just one dose" is safe—serious complications including gastric perforation have occurred after as few as 9-16 doses in elderly patients 7
• Do not use in patients with volume depletion or third-spacing (common post-operatively or with diuretic use) 4