Ketorolac
Ketorolac (tromethamine)
Toradol (IV/IM, US brand discontinued), Sprix (nasal spray), Acular and Acuvail (ophthalmic)
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Summary
Common uses
Moderate-to-severe acute pain, short-term (FDA)0, Postoperative pain, opioid-sparing (FDA)0, Acute migraine (off-label, IV/IM)0, Post-cataract surgical inflammation (FDA, ophthalmic)0, Seasonal allergic conjunctivitis (FDA, ophthalmic)0
Pharmacy
Starting dose
IM: 60 mg single dose or 30 mg every 6 hours. IV: 30 mg every 6 hours. Oral (continuation only): 10-20 mg every 4-6 hours. Sprix nasal: 31.5 mg every 6-8 hours. Maximum 5 days total combined use
Preparations
Tablets 10 mg; injection 15 mg/mL and 30 mg/mL; nasal spray 15.75 mg/spray (Sprix); ophthalmic solution 0.4%, 0.45%, 0.5%
US FDA Max
120 mg/day (IV/IM); 40 mg/day (oral); 5-day maximum total combined therapy to mitigate the GI bleeding, AKI, and platelet dysfunction risks
Pharmacology
Routes
Oral (continuation only), IV, IM, intranasal, ophthalmic
Onset
30 minutes (IM); 30-60 minutes (oral)
Duration
4-6 hours
Half-life
5-6 hours[1]
Bioavailability
~100% (oral, but oral use is limited to continuation from parenteral)[1]
Pregnancy
Avoid from 20 weeks gestation onward per FDA's 2020 expanded NSAID warning; contraindicated from 30 weeks. Specifically contraindicated in labor and delivery due to inhibition of uterine contractions[1]
Legal status
Rx-only in US
Purported mechanism
Non-selective COX-1/COX-2 inhibitor with unusually potent analgesic effect: the IV dose has been shown comparable to morphine for moderate-to-severe acute pain in postoperative trials, the basis of its opioid-sparing role. Anti-inflammatory effect is similar to other NSAIDs at the molar level; the analgesic potency is the distinguishing feature.0 Stricter dose-duration limits than any other NSAID (≤5 days, parenteral as primary route, continuation oral only) based on documented elevated risk of GI bleeding, acute kidney injury, and platelet dysfunction with prolonged use. Acute kidney injury risk is particularly elevated in dehydrated postoperative patients and contraindicates ketorolac in volume-depleted states. Not appropriate for chronic pain in elderly[1].
References
- ↑ 1.0 1.1 1.2 1.3 FDA Prescribing Information, Toradol (ketorolac tromethamine), Roche/various, current revision. https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/019645s022lbl.pdf