Toradol (ketorolac tromethamine) is a nonsteroidal anti-inflammatory drug (NSAID) indicated for the short-term management of moderately severe acute pain. It represents a critical therapeutic option in clinical settings where potent analgesia is required, yet the risks associated with opioid use are a significant concern. As a peripherally acting agent, it provides effective pain control by inhibiting prostaglandin synthesis, offering a valuable alternative for appropriate patient populations. Its use is strictly limited to a short duration due to the potential for serious adverse effects, positioning it as a powerful tool in the acute pain management arsenal.

Features

• Active Ingredient: Ketorolac tromethamine.
• Drug Class: Nonsteroidal anti-inflammatory drug (NSAID).
• Available Formulations: Oral tablets, intravenous (IV), and intramuscular (IM) injections.
• Mechanism of Action: Potent inhibitor of cyclooxygenase (COX-1 and COX-2) enzymes, reducing the synthesis of prostaglandins, which are mediators of pain, inflammation, and fever.
• Onset of Action: Rapid; analgesic effect begins within 30-60 minutes for IM injection and within 30-40 minutes for IV administration.
• Duration of Analgesia: Approximately 4-6 hours per dose for parenteral forms.
• Bioavailability: Nearly 100% for IM injection; oral bioavailability is approximately 80-100%.
• Half-life: Ranges from 3.5 to 9 hours in healthy adults, with an average of 5-6 hours.
• Metabolism: Primarily hepatic via conjugation and glucuronidation.
• Excretion: Predominantly renal (approximately 91% of a dose is excreted in the urine, with about 60% as metabolites and 40% as unchanged drug).

Benefits

• Provides potent analgesia comparable to certain opioids for moderate to severe acute pain, without the associated risks of respiratory depression, sedation, or physical dependence.
• Offers a non-opioid pain management strategy, which is crucial in the context of the opioid epidemic and for patients with a history of substance use disorder.
• Exhibits anti-inflammatory properties in addition to its analgesic effects, addressing the underlying inflammatory component of many painful conditions.
• Suitable for use in a hospital setting for post-operative pain, facilitating earlier mobilization and potentially improving recovery outcomes.
• Available in both parenteral and oral formulations, allowing for a transition from IV/IM to oral therapy within the strict limits of the total combined duration of therapy.

Common use

Toradol is specifically indicated for the short-term (up to 5 days) management of moderately severe acute pain that requires analgesia at the opioid level. Its use is almost exclusively reserved for acute scenarios in a controlled medical environment. The most frequent applications include:

• Management of post-operative pain following surgical procedures.
• Relief of pain associated with acute musculoskeletal injuries, such as fractures, sprains, and strains.
• Treatment of pain from renal colic (kidney stones).
• Use in emergency departments for acute migraine attacks that are unresponsive to first-line therapies.

It is not indicated for minor or chronic pain conditions, for use in labor and delivery, or as a prophylactic analgesic before surgery.

Dosage and direction

Dosing is highly dependent on the patient’s age, renal function, route of administration, and overall risk profile for adverse events. The total duration of therapy (oral + parenteral) must not exceed 5 days.

Parenteral (IV/IM) Dosing for Patients with Normal Renal Function:

• Single-Dose Treatment: IM: 60 mg; IV: 30 mg.
• Multiple-Dose Treatment:
  • Patients < 65 years and > 50 kg: 30 mg every 6 hours. Maximum daily dose: 120 mg.
  • Patients < 65 years and < 50 kg, or patients > 65 years: 15 mg every 6 hours. Maximum daily dose: 60 mg.

Oral Dosing (Following Parenteral Therapy):

• Patients < 65 years and > 50 kg: 20 mg as first oral dose, then 10 mg every 4 to 6 hours. Maximum daily dose: 40 mg.
• Patients < 65 years and < 50 kg, or patients > 65 years: 10 mg every 4 to 6 hours. Maximum daily dose: 40 mg.

Direction: The oral formulation is used only as continuation therapy following parenteral Toradol. It must be taken with a full glass of water and with food or milk to minimize gastrointestinal upset. The lowest effective dose should be used for the shortest duration possible.

Precautions

Toradol carries a significant risk of serious adverse events, necessitating extreme caution.

• Gastrointestinal (GI) Risk: Carries a high risk of serious GI adverse events including bleeding, ulceration, and perforation, which can be fatal. These events can occur at any time, with or without warning symptoms.
• Cardiovascular Thrombotic Risk: NSAIDs, including Toradol, increase the risk of serious and sometimes fatal cardiovascular thrombotic events, myocardial infarction, and stroke.
• Renal Toxicity: Long-term administration can lead to renal papillary necrosis and other renal injury. Use is contraindicated in patients with advanced renal disease and must be used with extreme caution in those with pre-existing renal impairment or volume depletion.
• Hepatotoxicity: Can cause elevations in liver enzymes and, in rare cases, severe hepatic reactions.
• Hematologic Effects: May inhibit platelet aggregation and prolong bleeding time; use with caution in patients with coagulation disorders or on anticoagulant therapy.
• Use in Special Populations: Use during the third trimester of pregnancy is contraindicated. Avoid use in nursing mothers. Use in pediatric patients is not recommended.

Contraindications

Toradol is contraindicated in the following scenarios:

• Hypersensitivity to ketorolac, aspirin, or other NSAIDs (manifested by asthma, urticaria, or other allergic-type reactions).
• Patients with a history of, or active, peptic ulcer disease or GI bleeding.
• Patients with advanced renal impairment or patients at risk for renal failure due to volume depletion.
• As prophylactic analgesia before major surgery.
• For intra-operative use when hemostasis is critical.
• In combination with other NSAIDs, including aspirin.
• In patients with suspected or confirmed cerebrovascular bleeding.
• For the treatment of peri-operative pain in the setting of coronary artery bypass graft (CABG) surgery.
• During the third trimester of pregnancy and in labor and delivery.
• In nursing mothers.

Possible side effect

The most common side effects are related to its GI and systemic effects. Patients should be monitored closely.

• Very Common (>10%): Nausea, dyspepsia, gastrointestinal pain.
• Common (1-10%): Diarrhea, constipation, flatulence, vomiting, headache, dizziness, drowsiness, sweating, injection site pain (with IM formulation).
• Uncommon (0.1-1%): Peptic ulcer, GI hemorrhage, perforation, hypertension, palpitations, skin reactions (rash, pruritus), fluid retention, edema.
• Rare (<0.1%): Acute renal failure, interstitial nephritis, anaphylactoid reactions, bronchospasm, severe hepatic reactions (e.g., hepatitis, jaundice), Stevens-Johnson syndrome, agranulocytosis, aplastic anemia.

Drug interaction

Toradol has numerous and significant drug interactions that must be carefully managed.

• Other NSAIDs and Aspirin: Concomitant use is contraindicated due to additive toxicity and no therapeutic benefit.
• Anticoagulants (e.g., Warfarin) and Antiplatelets (e.g., Clopidogrel): Increases the risk of serious GI bleeding.
• Selective Serotonin Reuptake Inhibitors (SSRIs) and SNRIs: Increase the risk of bleeding.
• ACE Inhibitors, ARBs, and Diuretics: Concomitant use may impair renal function and reduce the antihypertensive effect of these drugs.
• Lithium: Toradol can decrease lithium clearance, leading to increased lithium plasma levels and potential toxicity.
• Methotrexate: Can reduce the clearance of methotrexate, increasing the risk of methotrexate toxicity.
• Probenecid: Concurrent use is contraindicated as it significantly increases ketorolac plasma levels and half-life.
• Pentoxifylline: Concomitant use may increase the risk of bleeding.

Missed dose

As Toradol is used for acute pain on an as-needed schedule, the concept of a “missed dose” is not typically applicable in the same way as for chronic medications. If a dose is scheduled and missed, it should be taken as soon as it is remembered. However, if it is almost time for the next scheduled dose, the missed dose should be skipped. The patient should never double the dose to make up for a missed one. The strict 5-day limit on therapy must still be adhered to.

Overdose

Overdose may manifest as symptoms of NSAID toxicity.

• Symptoms: Primarily lethargy, drowsiness, nausea, vomiting, and epigastric pain. More severe overdose may lead to GI bleeding, hypertension, acute renal failure, and respiratory depression.
• Management: There is no specific antidote. Management is supportive and symptomatic. Gastric lavage or activated charcoal may be considered if ingestion was recent. Forced diuresis, alkalinization of the urine, or hemodialysis are not effective due to Toradol’s high protein binding and extensive metabolism.

Storage

• Store at room temperature (20°C to 25°C or 68°F to 77°F), away from light, moisture, and heat.
• Do not freeze.
• Keep all medications out of the reach of children and pets.
• Do not flush medications down the toilet or pour them into a drain unless instructed to do so. Properly discard this product when it is expired or no longer needed.

Disclaimer

This information is for educational and informational purposes only and does not constitute medical advice. It is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition or before starting any new treatment. Never disregard professional medical advice or delay in seeking it because of something you have read here. The use of Toradol (ketorolac tromethamine) must be supervised by a qualified healthcare professional due to its significant risk profile.

Reviews

• “As an anesthesiologist, Toradol is an indispensable part of our multimodal analgesia protocol for post-operative patients. Its ability to provide opioid-level pain relief while mitigating opioid-related side effects has significantly improved our patient recovery pathways.” – Dr. E. Lawson, MD
• “In the emergency department, IV Toradol is our go-to for severe renal colic and migraines. The speed of onset and efficacy are remarkable. However, its use requires vigilant patient selection and strict adherence to the short-term dosing limits to avoid complications.” – Physician Assistant, Urban ED
• “This medication was administered to me after orthopedic surgery. The pain relief was almost immediate and far more effective than the opioid I was also prescribed, without the grogginess. I was grateful for a non-opioid option that worked so well.” – Patient J.S.
• “From a clinical pharmacist’s perspective, Toradol is a high-alert medication. Its benefits are potent, but its contraindications and drug interaction profile demand extreme diligence from the entire healthcare team during ordering, dispensing, and administration.” – Clinical Pharmacist, R.Ph.