Ketorolac × Meloxicam

Ketorolac outweighs other NSAIDs in antiplatelet and ulcerogenic effect. Its label places treatment with aspirin or other NSAIDs, selective COX-2 inhibitors included, among the contraindications, and the interactions section states it must not be used with other NSAIDs because of the increased rate of serious class adverse effects: gastrointestinal bleeding and perforation, renal injury, and bleeding from platelet inhibition. Analgesia does not improve when the second drug is added, since the target is the same enzyme family – cyclooxygenase.

Black or tarry stools, coffee-ground vomit, epigastric pain, sudden weakness and pallor from anaemia. Falling urine output and swelling as a sign of renal injury. In older people and those with a history of ulcer the picture may begin with the bleed itself, without preceding pain.

The combination is taken apart: one NSAID remains. For severe pain that is usually ketorolac in a short course within the label limit, with the rest of the analgesia covered by paracetamol, metamizole or an opioid. Gastroprotection with a proton pump inhibitor does not lift the contraindication. After a ketorolac dose, another NSAID is not added until its action ends, not merely until the next scheduled dose.