Clinical beta

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Drug Monograph

Ketorolac

USE IF: Moderate-severe acute pain (post-op, trauma, renal colic), opioid-sparing strategy

AVOID IF: GI bleed risk, renal impairment, volume depletion, >5 days use

Ketorolac

Non-selective NSAID (COX-1 > COX-2 inhibitor)

NSAIDAcute painOpioid-sparingHigh GI riskShort-term only

Indication

Moderate-severe acute pain (post-op, trauma, renal colic), opioid-sparing strategy

At a glance

INDICATION -> Short-term moderate-severe acute pain requiring opioid-level analgesia

ADULT DOSE -> 15–30 mg IV q6h depending on patient type

MAX DOSE -> 120 mg/day (young healthy adults); 60 mg/day (elderly/<50 kg/renal risk)

CONTRA -> GI bleed risk, renal impairment, volume depletion, >5 days use

ANTIDOTE -> None (supportive care only)

Quick facts

Onset

15–30 min (IV), ~30 min (IM/PO), 20–30 min (intranasal)

Duration

Peak 1–2 h; duration 4–6 h (up to 8 h at higher doses). Half-life ~3.5–9 h (longer in elderly/renal impairment).

Routes

IV, IM, PO (step-down), intranasal, ophthalmic

Pregnancy

Avoid >=20 weeks; contraindicated in 3rd trimester

Renal

Avoid in significant impairment

Hepatic

Use cautiously

Do not miss

Time to action: IV onset 15—30 min

Max duration

  • ABSOLUTE MAX: 5 days total (all routes combined) — no exceptions due to high GI/renal risk.

Critical risks

  • GI bleeding risk (highest among NSAIDs).
  • Acute renal failure.
  • Cardiovascular thrombotic events.

Antidote

  • No specific antidote.
  • Supportive care only.

High-risk scenarios

  • Elderly.
  • Hypovolemia.
  • CKD.
  • Anticoagulated patients.

Key interactions

  • Anticoagulants.
  • Lithium.
  • Methotrexate.
  • ACEi/ARB + diuretics.

Indications

Primary

  • Postoperative pain
  • Trauma pain
  • Musculoskeletal pain
  • Renal colic

Secondary

  • Multimodal analgesia
  • Sickle cell crisis adjunct
  • Ophthalmic inflammation

Other

  • Acute migraine
  • Biliary colic
  • Dysmenorrhea (off-label)

Dosing

Standard: IV 30 mg q6h (healthy adult)

Max daily dose

  • Healthy younger adults: max 120 mg/day.
  • Elderly/<50 kg/renal risk: max 60 mg/day.
  • Do not exceed 60 mg/day in elderly, low body weight (<50 kg), or renal impairment.
  • Absolute black-box duration limit: <=5 days total.

Adult - PO

  • Only after IV/IM therapy.
  • 10 mg q4–6h (max 40 mg/day).

Adult - IV

  • <65 years and >=50 kg: 30 mg q6h (max 120 mg/day).
  • >=65 years or <50 kg: 15 mg q6h (max 60 mg/day).

Pediatric

  • >=2 years: 0.5 mg/kg IV/IM q6h (max 15 mg/dose, 60 mg/day).

Renal adjustment

  • Mild impairment: reduce dose by ~50%.
  • Severe impairment: contraindicated.

Hepatic adjustment

  • No formal adjustment; use cautiously.

Warnings

Clinical warnings

  • Highest GI bleeding risk among NSAIDs.
  • Acute renal failure risk (especially with hypovolemia).
  • Cardiovascular thrombotic risk (MI/stroke).
  • Platelet inhibition -> increased bleeding.
  • Contraindicated peri-CABG and in active bleeding.
  • Bronchospasm risk in NSAID-sensitive asthma.
  • Delayed wound/bone healing with prolonged use.

Adverse effects

  • Common: dyspepsia, nausea, dizziness, injection-site discomfort.
  • Serious: GI hemorrhage, AKI, severe hypertension, CV events.

Contraindications / caution

Do not use

  • Active GI bleeding or peptic ulcer disease.
  • Severe renal impairment (eGFR <30).
  • Volume depletion.
  • Hemorrhagic disorders.
  • Perioperative CABG.
  • Post-operative CABG (absolute contraindication).
  • Pregnancy (3rd trimester).
  • Concurrent NSAID use.

Use caution / avoid high doses

  • Elderly.
  • Anticoagulated patients.
  • Hypertension / cardiovascular disease.
  • Liver disease.
  • ACEi/ARB + diuretics.

Drug interactions

  • Anticoagulants -> severe bleeding risk.
  • Antiplatelets -> additive bleeding.
  • Other NSAIDs -> contraindicated.
  • Lithium -> toxicity (reduced clearance).
  • Methotrexate -> toxicity.
  • ACEi/ARB + diuretics -> AKI (triple whammy).
  • SSRIs -> increased GI bleed risk.
  • Corticosteroids -> additive GI injury.

Special populations

Pediatrics

>=2 years specialist/weight-based use.

Pregnancy

Avoid after 20 weeks; contraindicated in 3rd trimester.

Breastfeeding

Contraindicated.

Elderly

Use ~50% dose reduction; higher GI/renal risk.

Liver disease

Avoid in severe cirrhosis/ascites.

Renal impairment

Avoid in moderate-severe impairment.

Administration

  • IV slow push over >=15–30 seconds.
  • IM deep injection.
  • PO only after parenteral use.
  • Intranasal route can be used when IV access is unavailable.
  • Do not mix with morphine/promethazine in the same syringe.
  • Take oral doses with food.
  • Always document stop date (<=5 days total).

Monitoring

  • Creatinine at baseline and again around 24–48 hours.
  • Hemoglobin if bleeding risk is present.
  • GI bleeding signs (melena, hematemesis).
  • Urine output.
  • Blood pressure.
  • Pain score.
  • Total duration tracking (critical).

Overdose / toxicity

IF SUSPECTED KETOROLAC OVERDOSE: stop drug immediately.

Recognition

  • GI bleeding, renal failure, hypertension, CV events.
  • No specific antidote exists.

Immediate actions

  • IV fluids.
  • IV PPI if GI bleeding is suspected/confirmed.
  • Consider PPI therapy for GI protection if bleeding risk.
  • Monitor renal function closely.
  • Endoscopy for significant GI bleeding.

Antidote

  • No specific antidote.

Decontamination

  • Per toxicology protocol when indicated.

Escalation

  • ICU if severe AKI or hemorrhage.

Clinical pearls

Common mistakes, resistance logic, and bedside traps

GI risk first

  • Most gastrotoxic NSAID; always screen for GI risk.

Dose efficiency

  • 10 mg IV can provide analgesia close to 30 mg IV; use the lowest effective dose.

ER utility

  • Excellent for renal colic and acute migraine in emergency settings.

Opioid-sparing

  • Strong opioid-sparing effect in multimodal analgesia.

PPI strategy

  • Co-prescribe PPI in high-risk GI patients when appropriate.

Hydration safety

  • Avoid in dehydrated/hypovolemic patients.

Platelet effect

  • Platelet inhibition is reversible.

Five-day rule

  • Never exceed 5 days total treatment - most important safety rule.

Pharmacokinetics

  • High bioavailability across IV/IM/PO routes.
  • ~99% protein bound.
  • Hepatic metabolism.
  • Primarily renal excretion (~90%).
  • Half-life is prolonged in elderly and renal impairment.

Mechanism of action

  • Non-selective COX inhibitor.
  • Reduced prostaglandin synthesis drives analgesia.
  • COX-1 dominance contributes to GI, renal, and platelet toxicity.

Common brand names

Saudi Arabia

Toradol · Ketrolac · Rikedol · Senorolac · Torolac

Global

SPRIX · Acular · Acuvail · Ketanov · Ketorolac (generic)

Common trade names are curated examples only — formulations and availability vary. Verify the exact product name with your local pharmacy and national regulator before prescribing or dispensing.

Country practice notes

  • Widely available across GCC hospitals and emergency settings.
  • Commonly used as first-line opioid-sparing analgesic in ER protocols.
  • UAE has broad brand availability (Toradol, Ketrolac, Rikedol, Senorolac, Acular LS, Torolac).
  • Saudi Arabia and GCC: standard formulary NSAID for acute pain and post-op care.
  • No major regulatory restriction (non-controlled drug).

Saudi Arabia — confirm with local formulary.