What is the recommended IV ketorolac dosing for adults, including adjustments for patients aged ≥65 years, creatinine clearance <50 mL/min, and relevant contraindications?

IV Ketorolac Dosing for Adults

For adults under 65 years, the recommended IV dose is 30 mg every 6 hours (maximum 120 mg/day), while patients ≥65 years, those with creatinine clearance <50 mL/min, or weighing <50 kg should receive 15 mg every 6 hours (maximum 60 mg/day), with treatment never exceeding 5 consecutive days. 1

Standard Dosing by Patient Population

Adults <65 Years (Normal Renal Function, ≥50 kg)

• Single-dose regimen: 30 mg IV bolus over at least 15 seconds 1
• Multiple-dose regimen: 30 mg IV every 6 hours, maximum 120 mg/day 1
• Analgesic effect begins in approximately 30 minutes with maximum effect at 1-2 hours 1
• Duration of effect is typically 4-6 hours 1

Adults ≥65 Years

• Single-dose regimen: 15 mg IV over at least 15 seconds 1
• Multiple-dose regimen: 15 mg IV every 6 hours, maximum 60 mg/day 1
• Elderly patients have substantially higher risk of gastrointestinal toxicity and should receive reduced doses regardless of renal function 2, 1
• Recent evidence suggests 15 mg IV provides equivalent analgesia to 30 mg IV in elderly patients without increased need for rescue medication 3

Renal Impairment (Creatinine Clearance <50 mL/min)

• Dosing: 15 mg IV every 6 hours, maximum 60 mg/day 1
• Contraindicated in advanced renal impairment or patients at risk for renal failure due to volume depletion 1
• Hypovolemia must be corrected prior to ketorolac administration 1
• Monitor BUN and creatinine; discontinue if values double 2

Patients <50 kg (110 lbs)

• Single-dose: 15 mg IV 1
• Multiple-dose: 15 mg IV every 6 hours, maximum 60 mg/day 1

Critical Duration Limitation

• Maximum treatment duration: 5 consecutive days total (IV plus oral combined) 1, 2
• This is an absolute maximum, not a "per month" allowance 2
• Repeated 5-day courses within the same month are not evidence-based and should be avoided 2
• "Cycling" on and off ketorolac lacks clinical data support 2
• Increasing dose or frequency beyond recommendations increases serious adverse event risk without improving efficacy 1, 4

Absolute Contraindications

Ketorolac is contraindicated in: 1, 2

• Active or history of peptic ulcer disease or gastrointestinal bleeding
• Advanced renal impairment or creatinine clearance <50 mL/min (for standard dosing)
• Cerebrovascular bleeding or hemorrhagic diathesis
• Suspected or confirmed bleeding disorders
• Thrombocytopenia or concurrent anticoagulant use
• Coronary artery bypass graft (CABG) surgery setting
• Aspirin/NSAID-induced asthma or hypersensitivity
• Pregnancy, labor, delivery, or breastfeeding
• Concurrent use with other NSAIDs or aspirin

High-Risk Populations Requiring Extreme Caution

• Age >60 years with history of significant alcohol use or hepatic dysfunction 2
• Heart failure or uncontrolled hypertension (monitor blood pressure; discontinue if hypertension worsens) 2
• Concurrent nephrotoxic drugs (increased renal toxicity risk) 2
• Patients on ACE inhibitors or diuretics (drug interaction concerns) 2
• History of cardiovascular disease (increased thrombotic event risk) 1, 2

Monitoring Requirements

For patients receiving ketorolac, monitor: 2

• Blood pressure at baseline and periodically
• BUN and creatinine (discontinue if values double)
• Liver function tests (discontinue if elevated)
• Complete blood count
• Fecal occult blood
• Signs of fluid retention, edema, or dyspnea suggesting heart failure

Administration Technique

• IV bolus must be given over at least 15 seconds 1
• Do not mix in syringe with morphine, meperidine, promethazine, or hydroxyzine (causes precipitation) 1
• Inspect solution for particulate matter and discoloration before administration 1

Analgesic Ceiling Effect

• Doses above 10-15 mg IV provide no additional analgesic benefit but increase adverse event risk 4, 3
• A randomized trial demonstrated equivalent pain reduction with 10 mg, 15 mg, and 30 mg IV doses at 30 minutes (mean pain score reductions of 2.6,2.5, and 3.0 respectively) 4
• For breakthrough pain, do not increase dose or frequency; instead consider supplementing with low-dose opioids unless contraindicated 1

Safer Alternatives When Ketorolac Is Inappropriate

• Acetaminophen up to 4 g daily for patients with cardiovascular or renal concerns 2, 5
• Oral NSAIDs (ibuprofen 400-800 mg every 6-8 hours, maximum 3200 mg/day) for pain beyond 5 days 5
• Low-dose oral opioids (morphine, oxycodone) with antiemetic coverage for NSAID contraindications 5
• Opioids without active metabolites (methadone, buprenorphine, fentanyl) for severe renal impairment 2

Common Pitfalls to Avoid

• Do not exceed 5 days total duration regardless of route or clinical response 1, 2
• Do not use standard adult doses in elderly patients even if renal function appears normal 1
• Do not administer to volume-depleted patients without first correcting hypovolemia 1
• Do not combine with other NSAIDs or aspirin due to cumulative toxicity risk 1
• Do not use doses >15 mg in high-risk populations (elderly, renal impairment, <50 kg) 1