What are the oral dosing guidelines for Toradol (ketorolac tromethamine) in adults (≥16 years), including dose, frequency, maximum daily dose, duration, and adjustments for age ≥65 years, body weight <50 kg, or impaired renal function?

Oral Toradol (Ketorolac) Dosing Guidelines

Oral ketorolac is ONLY indicated as continuation therapy following IV or IM ketorolac—it should never be used as initial treatment—and the combined duration of all routes must not exceed 5 days total. 1

Standard Oral Dosing by Patient Population

Adults Age 17–64 Years (Standard Risk)

• Initial oral dose: 20 mg once (as first oral dose after transitioning from IV/IM) 1
• Maintenance: 10 mg every 4–6 hours as needed 1
• Maximum daily dose: 40 mg/day 1
• Do NOT shorten the 4–6 hour dosing interval 1

High-Risk Patients (Age ≥65 Years, Weight <50 kg, or Renal Impairment)

• Initial oral dose: 10 mg once 1
• Maintenance: 10 mg every 4–6 hours as needed 1
• Maximum daily dose: 40 mg/day 1
• Do NOT shorten the 4–6 hour dosing interval 1

Pediatric Patients (Age <17 Years)

• Oral ketorolac is NOT approved for use in patients under 17 years of age 1

Absolute Maximum Duration: 5 Days Total

The 5-day limit applies to the COMBINED duration of IV, IM, and oral ketorolac—not 5 days per route. 2, 1, 3

• Once you start IV or IM ketorolac, the clock begins; oral continuation counts toward this same 5-day total 1
• Repeated 5-day courses within the same month are NOT supported by evidence and should be avoided 2
• "Cycling" on and off ketorolac or using it intermittently throughout a month lacks clinical data and is not recommended 2

Absolute Contraindications (Do Not Prescribe)

Ketorolac is contraindicated in patients with: 2, 4, 3, 5

• Active or history of peptic ulcer disease or gastrointestinal bleeding 2
• Aspirin/NSAID-induced asthma or hypersensitivity 2, 4
• Cerebrovascular bleeding or high cardiovascular risk 2
• Thrombocytopenia or concurrent anticoagulant/antiplatelet therapy 2
• Severe renal insufficiency or risk of renal failure 2, 4
• Pregnancy, labor, delivery, or nursing 5
• Age >60 years with significant alcohol use or hepatic dysfunction 2

Mandatory Baseline and Monitoring Requirements

Before Starting Ketorolac

Obtain baseline: 2, 4

• Blood pressure
• BUN and creatinine
• Liver function tests
• Complete blood count
• Fecal occult blood test

During Treatment

Monitor periodically and discontinue immediately if: 2, 4

• BUN or creatinine doubles
• Liver function tests increase (>3× upper limit of normal)
• Hypertension develops or worsens
• Any signs of gastrointestinal bleeding occur

Critical Drug Interactions and Timing

Avoid Concurrent NSAIDs

Never combine ketorolac with other NSAIDs (including ibuprofen, naproxen, aspirin)—toxicities are additive without additional analgesic benefit. 6

• If a patient has taken ibuprofen, wait 6–8 hours (approximately 3–4 half-lives) before administering ketorolac 6
• During this waiting period, use acetaminophen or opioids instead 6

Avoid Concurrent Nephrotoxic Drugs

Ketorolac increases renal toxicity risk when combined with other nephrotoxic agents (aminoglycosides, ACE inhibitors, diuretics) 2, 6

Safe Alternatives for Pain Beyond 5 Days

When patients require analgesia beyond the 5-day ketorolac limit: 2

• Acetaminophen up to 4 g/day is the preferred first-line option with a more favorable safety profile 2
• Oral NSAIDs with better safety margins (ibuprofen, naproxen) may be appropriate for subacute pain 2
• Low-dose oral opioids (morphine, oxycodone) or opioids without active metabolites (methadone, buprenorphine, fentanyl) for patients with cardiovascular or renal concerns 2

Alternating Ketorolac with Acetaminophen

Alternating oral ketorolac with acetaminophen 650 mg every 3 hours (staggered) is safe and provides more continuous pain coverage without overlapping toxicities. 6

• Acetaminophen lacks the gastrointestinal, renal, and platelet effects of NSAIDs 6
• Maximum acetaminophen dose: 3–4 g/day 6
• Acetaminophen can be continued long-term after ketorolac is stopped 6

Common Pitfalls to Avoid

• Never use oral ketorolac as initial therapy—it must follow IV/IM dosing 1
• Never exceed 5 days total across all routes of administration 2, 1, 3
• Never combine with other NSAIDs—wait for clearance or use alternative analgesics 6
• Never use prophylactically to prevent anticipated pain 3
• Never prescribe in elderly patients without dose reduction (use 10 mg dosing) 1
• Never ignore renal function—adjust dose or avoid entirely in renal impairment 1, 5