Ketorolac

Non-steroidal anti-inflammatory drugs (NSAIDs)

ATC code: M01AB15 (Ketorolac)

Mechanism of action

Non-selective COX-1 and COX-2 inhibitor with predominantly analgesic (rather than anti-inflammatory) effect. Analgesic potency is comparable to morphine for certain pain syndromes. Rapid onset: 30-60 minutes orally, 10-15 minutes intramuscularly. One of the most potent non-opioid analgesics.

Indications

Acute moderate-to-severe pain

First line

First-line for acute moderate-to-severe pain when rapid non-opioid analgesia is needed. Oral dose is 10 mg every 4-6 hours, maximum 40 mg daily. Course is strictly limited to 5 days. Beyond 5 days, the risk of GI bleeding and renal injury rises sharply. Not indicated for chronic pain.

Postoperative pain

First line

Widely used in the early postoperative period. Reduces opioid requirements by 25-45%. Intramuscularly or intravenously – 30 mg loading dose, then 15-30 mg every 6 hours. In patients over 65, weighing under 50 kg, or with renal impairment – maximum 60 mg daily. Total parenteral and oral course duration must not exceed 5 days.

Practical notes

Timing and administration

Course is strictly limited to 5 days total (parenteral + oral combined). This is not a recommendation but a hard label constraint. When switching from parenteral to oral, total duration is counted together. Reduced doses for elderly patients and those weighing under 50 kg.

Special situations

Ketorolac has the highest GI bleeding risk among NSAIDs. Do not combine with other NSAIDs, anticoagulants, or aspirin. Contraindicated in peptic ulcer disease, renal insufficiency, and perioperative CABG. In patients with GI risk factors, add a PPI even for the short course.

Safety

Boxed warning

Ketorolac is contraindicated for chronic pain management. Total treatment duration must not exceed 5 days. Increased risk of serious GI adverse events – bleeding, ulceration, perforation. Increased risk of cardiovascular thrombotic events.

Contraindications

Active peptic ulcer or history of GI bleeding
Severe renal impairment or risk of renal failure (hypovolemia, dehydration)
Perioperative setting in CABG surgery
Hemostatic disorders or concurrent anticoagulant use
Third trimester of pregnancy
Age under 16 years
Concurrent use of other NSAIDs

Serious adverse effects

GI bleeding, perforation – highest risk among NSAIDs
Acute kidney injury
Bronchospasm in patients with aspirin-exacerbated respiratory disease
Cardiovascular thrombotic events (with prolonged use)

Common adverse effects

Dyspepsia, nausea, abdominal pain
Headache, dizziness
Drowsiness
Edema

PregnancyFDA C

FDA category C in the first and second trimesters. Contraindicated in the third trimester (category D) – causes premature ductus arteriosus closure and oligohydramnios. Avoid after 20 weeks.

Breastfeeding

Passes into breast milk in small amounts. Short-term use (1-2 days) is acceptable during breastfeeding per LactMed.