IM Ketorolac Dosing Frequency
Intramuscular ketorolac should be administered every 6 hours, with a maximum treatment duration of 5 consecutive days regardless of route. 1
Standard Dosing Intervals
- Administer IM ketorolac every 6 hours for multiple-dose treatment 1
- The analgesic effect begins in approximately 30 minutes with maximum effect at 1-2 hours, and duration of 4-6 hours 1
Maximum Daily Doses
For patients under 65 years:
- 30 mg IM every 6 hours
- Maximum daily dose: 120 mg/day 1
For patients ≥65 years, renally impaired, or <50 kg body weight:
Critical Duration Limit
- Treatment must not exceed 5 consecutive days total, combining all routes (IV, IM, or oral) 1, 3
- This 5-day limit is absolute and applies to continuous therapy—repeated 5-day courses within the same month are not evidence-based and should be avoided 3
- "Cycling" on and off ketorolac lacks clinical data support and is not recommended 3
Breakthrough Pain Management
- Do not increase the dose or frequency of ketorolac for breakthrough pain 1
- Instead, consider supplementing with low-dose opioids as needed (unless contraindicated) 1
- Alternatively, acetaminophen up to 4 g/day can be alternated with ketorolac every 3 hours to provide more continuous coverage 4
Key Safety Considerations
Absolute contraindications include: 3
- Active peptic ulcer disease or GI bleeding history
- Cerebrovascular bleeding
- Severe renal impairment
- Concurrent anticoagulant therapy
- Aspirin/NSAID-induced asthma
High-risk populations requiring dose reduction (15 mg every 6 hours): 1, 2
- Age ≥60 years (significantly elevated risk for renal, GI, and cardiovascular toxicity)
- Renal insufficiency
- Body weight <50 kg
- History of significant alcohol use or hepatic dysfunction
Monitoring Requirements
Baseline assessment before initiating ketorolac: 3, 2
- Blood pressure
- BUN and creatinine
- Liver function tests
- Complete blood count
- Fecal occult blood
Discontinue immediately if: 3
- BUN or creatinine doubles
- Hypertension develops or worsens
- Liver function tests increase >3× upper limit of normal
- Unexplained dyspnea or edema suggesting heart failure occurs
Common Pitfalls to Avoid
- Never combine ketorolac with other NSAIDs (including ibuprofen)—this markedly increases toxicity without added analgesic benefit 3, 4
- Wait 6-8 hours after the last ibuprofen dose before administering ketorolac to allow adequate drug clearance 4
- Avoid concurrent use with SSRIs, SNRIs, or anticoagulants due to significantly increased bleeding risk 3, 2
- Do not extend therapy beyond 5 days—switch to safer alternatives like acetaminophen (up to 4 g/day) or oral NSAIDs with better safety profiles (ibuprofen 1200-2400 mg/day or naproxen 500-1000 mg/day) for longer-term needs 3