Ketorolac

Mechanism

Apixaban inhibits factor Xa, while ketorolac is the most potent available NSAID. Ketorolac injures the gastric mucosa and inhibits platelet aggregation. Massive GI bleeding risk increases several-fold. FDA Toradol Section 4.3 lists anticoagulants as contraindications.

Symptoms

Gum bleeding, epistaxis, bruising without trauma, blood in urine or stool, menorrhagia. Severe cases include gastrointestinal or intracranial haemorrhage. Risk rises in patients over 65 and with prior peptic ulcer disease.

Management

The combination is not prescribed. For analgesia in a patient on apixaban, use paracetamol (up to 3 g/day), metamizole, or a short opioid course. Ketorolac courses never exceed 5 days under any circumstances.

Mechanism

Dual NSAID therapy – additive GI bleeding, nephrotoxicity, and cardiovascular event risks. Ketorolac itself is limited to 5 days of use.

Symptoms

Black or tarry stools (melena), vomiting blood or coffee-ground material, epigastric pain. Risk multiplies in older patients and with prior peptic ulcer disease.

Management

The combination is not prescribed. One NSAID at a time. For enhanced analgesia, add paracetamol or a short opioid course, not a second NSAID.

Mechanism

Additive nephrotoxicity. Ketorolac (NSAID) suppresses prostaglandin-dependent renal blood flow; iodinated contrast (iopromide) adds osmotic load. High risk of acute kidney injury.

Symptoms

Reduced urine output, rising creatinine, proteinuria. Severe cases include oliguria and need for haemodialysis. Symptoms appear 1–3 days after contrast.

Management

Stop ketorolac 48 hours before planned contrast and resume 48 hours after with stable renal function. Alternative analgesics: paracetamol, metamizole, or a short opioid course. Provide contrast nephroprotection with adequate saline hydration.

Mechanism

Dual NSAID therapy – additive GI bleeding and nephrotoxicity risk. Despite meloxicam's preferential COX-2 selectivity, GI toxicity adds up when combined with ketorolac.

Symptoms

Black or tarry stools, vomiting blood, epigastric pain. Risk multiplies in older patients and with prior peptic ulcer disease.

Management

The combination is not prescribed. One NSAID at a time. Ketorolac courses no more than 5 days. For enhanced analgesia: paracetamol or a short opioid.

Mechanism

Ketorolac reduces renal methotrexate clearance and suppresses tubular secretion. At high oncologic methotrexate doses: risk of severe toxicity (pancytopenia, nephrotoxicity, mucositis).

Symptoms

Mouth ulcers (mucositis), nausea, diarrhoea, hair loss. Blood counts fall: leukocytes, platelets, erythrocytes. Severe cases: fatal pancytopenia, nephrotoxicity.

Management

At oncologic methotrexate doses, the combination is not prescribed. At low rheumatologic doses, avoid ketorolac; use paracetamol or a short opioid course for analgesia. Ketorolac courses never exceed 5 days.

Mechanism

Dual NSAID therapy – sharp rise in GI bleeding risk (3- to 5-fold), acute kidney injury, and cardiovascular events.

Symptoms

Black or tarry stools, vomiting blood, epigastric pain. Risk multiplies in older patients and with prior peptic ulcer disease.

Management

The combination is not prescribed. One NSAID at a time. For enhanced analgesia: paracetamol or a short opioid course, not a second NSAID. Ketorolac courses never exceed 5 days.

Mechanism

Ketorolac inhibits platelet aggregation and strongly injures the gastric mucosa. Combined with rivaroxaban (direct factor Xa inhibitor): additive massive GI bleeding risk. FDA Toradol Section 4.3 lists anticoagulants as contraindications.

Symptoms

Black or tarry stools (melena), vomiting blood or coffee-ground material, epigastric pain. Risk multiplies in older patients and with prior peptic ulcer disease.

Management

The combination is not prescribed. For analgesia on rivaroxaban, use paracetamol (up to 3 g/day), metamizole, or a short opioid course. Ketorolac courses never exceed 5 days under any circumstances.

Mechanism

Ketorolac is the most nephrotoxic NSAID, limited to 5 days of use. Tacrolimus is nephrotoxic in its own right. Additive acute kidney injury risk multiplies in transplant patients.

Symptoms

Reduced urine output, rising creatinine and potassium, oedema. Symptoms appear earlier in older patients and chronic kidney disease.

Management

The combination is not prescribed. For post-transplant analgesia: paracetamol (up to 2 g/day), metamizole, or a short opioid course. For neuropathic pain: gabapentin or pregabalin.

Mechanism

Ketorolac is the most potent available NSAID. It inhibits platelet aggregation and strongly injures the gastric mucosa. On warfarin, massive GI bleeding risk multiplies. FDA Toradol Section 4.3 lists anticoagulants as contraindications.

Symptoms

Gum bleeding, epistaxis, bruising without trauma, blood in urine or stool, menorrhagia. Severe cases include gastrointestinal or intracranial haemorrhage. Risk rises in patients over 65 and with prior peptic ulcer disease.

Management

The combination is not prescribed. For analgesia on warfarin, use paracetamol (up to 2 g/day), metamizole, or a short opioid course. Ketorolac courses never exceed 5 days under any circumstances.