Generic Name

Toradol

Mechanism

• Selective COX‑1 and COX‑2 inhibition:
• Ketorolac is a reversible, non‑selective cyclo‑oxygenase (COX) inhibitor, suppressing prostaglandin E₂ synthesis.
• COX‑1 blockade reduces gastrointestinal (GI) prostaglandins, predisposing to ulcers and bleeding.
• COX‑2 inhibition provides the primary analgesic and anti‑inflammatory effect.
• Peripheral and central effects:
• Decreases peripheral sensitization of nociceptors.
• Modest central nervous system penetration may augment analgesia without typical central side effects of opioids.

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Pharmacokinetics

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Indications

• Acute postoperative pain (≤ 5 days).
• Traumatic injury pain control (≤ 5 days).
• Acute gouty arthritis or inflammatory pain short‑term.
• Adjunct analgesia when opioid sparing is desired.

*Not approved for chronic pain management due to cumulative GI and renal toxicity.*

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Contraindications

• Absolute contraindications:
• History of hypersensitivity to ketorolac or other NSAIDs.
• Active GI ulceration or bleeding.
• Known renal insufficiency (CrCl < 30 mL/min).
• Pregnancy (3rd trimester) and lactation.
• Relative risks:
• Cardiovascular events (MI, stroke) in patients with pre‑existing CVD.
• Hepatic dysfunction.
• Severe comorbidities requiring prolonged use.

Warnings:
• GI complications: ulcer, perforation, bleeding.
• Renal impairment: AKI, acute tubular necrosis.
• Bleeding risk: coagulation interference; avoid concurrent anticoagulants.
• Caution in elderly: higher susceptibility to GI/renal side effects.

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Dosing

• Loading dose: 30 mg IV or IM may be considered for severe pain but rarely required.
• Titration: Start with lowest effective dose; increment only if pain persists and patient tolerates.
• Discontinuation: Stop abruptly after 5 days; switching to long‑acting analgesic (e.g., NSAID or opioid) is advisable for sustained pain.

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Adverse Effects

Common (≥ 2–5 %)
• Nausea, dyspepsia, abdominal discomfort.
• Headache, dizziness.
• Somnolence, blurred vision.
• Minor edema or fluid retention.

Serious (≤ 1 %)
• GI ulceration, perforation, hemorrhage.
• Acute kidney injury (AKI), renal insufficiency.
• Bleeding diathesis (especially with anticoagulants).
• Hypersensitivity reactions (rash, angioedema).
• Pulmonary edema (rare).
• Cardiovascular events (MI, stroke).

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Monitoring

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Clinical Pearls

1. “Five‑day rule” – Toradol should not exceed 5 days of continuous therapy in any patient; this limits cumulative GI and renal risk while maintaining efficacy.

2. Avoid concurrent NSAIDs – Co‑administration can double the risk of GI bleeding; safe only if clinically justified and with gastroprotection.

3. Pre‑operative handover – Document prior NSAID exposure; patients with chronic NSAID use need tapering or alternative analgesia to prevent AKI.

4. Elderly caution – Their decreased renal reserve and increased GI fragility make dosing at the low end of the spectrum imperative; consider 5 mg q6h PO.

5. Post‑delivery postpartum – Not recommended due to bleeding risk; use paracetamol/acetaminophen as first line.

6. Acute gout flare – Ketorolac’s COX‑2 inhibition offers anti‑inflammatory benefit, but be wary of renal congestion; check serum creatinine before use.

7. Drug–drug synergy – Ketorolac increases warfarin’s INR; hold warfarin for 24 h after last ketorolac dose and recheck INR.

8. Enteral administration – Take on an empty stomach with plenty of water to improve absorption; avoid food which can delay onset by 20–30 min.

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• *Sources: UpToDate (2023), FDA prescribing info for Toradol, NCCN Clinical Practice Guidelines for Pain Management.*