CriticalNon-steroidal anti-inflammatory drugs (NSAIDs)×Vitamin K antagonist anticoagulants
Updated · Methodology
Mechanism
Ketorolac inhibits platelet aggregation, prolongs bleeding time and damages the gastric mucosa; according to its SmPC it causes serious gastrointestinal toxicity more often than equivalent doses of other NSAIDs. NSAIDs enhance the effect of coumarin anticoagulants such as warfarin on bleeding time, and patients taking warfarin with an NSAID have a higher risk of serious gastrointestinal bleeding than with either drug alone.
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 contraindicated: Spanish ketorolac SmPCs (10 mg tablets, 30 mg/ml injection) contraindicate ketorolac in patients on coumarin anticoagulants, and warfarin is one of them (ketorolac SmPCs). The originator SmPC (Toradol) lists anticoagulants among combinations that are not recommended and asks for maximum caution with warfarin (Toradol SmPC). The FDA allows such therapy only with extreme caution, after weighing benefits against risks and with close monitoring (US ketorolac label). If the patient has already received ketorolac, stop it at once if gastrointestinal bleeding is suspected (ketorolac SmPCs); whenever a drug is started or stopped in a patient on warfarin, monitor the INR closely (warfarin SmPC).
Check the full regimen, not just this pair
Opens the checker with these two drugs prefilled. Add the rest of the regimen and recompute additive risks.
Summary of a multi-drug list →
Medicine list: everything you take in one place →
Sources
- AEMPS: Ficha técnica: Ketorolaco trometamol 10 mg (Qualigen) (nº registro 70105), secciones 4.2, 4.3, 4.4 y 4.5 (2026)– AEMPS, CIMA, nº registro 70105, revisión 01/2026, secciones 4.2, 4.3, 4.4 y 4.5
- AEMPS: Ficha técnica: Ketorolaco trometamol 30 mg/ml (Normon) (nº registro 70102), secciones 4.3 y 4.5 (2023)– AEMPS, CIMA, nº registro 70102, revisión 08/2023, secciones 4.3 y 4.5
- AEMPS: Ficha técnica: Ketorolaco trometamol 30 mg/ml (Toradol) (nº registro 58976), secciones 4.4 y 4.5 (2023)– AEMPS, CIMA, nº registro 58976, revisión 07/2023, secciones 4.4 y 4.5
- AEMPS: Ficha técnica: Warfarina 5 mg (Aldocumar) (nº registro 63064), sección 4.5 (2023)– AEMPS, CIMA, nº registro 63064, revisión 01/2023, sección 4.5
- FDA: Ketorolac tromethamine tablets prescribing information (Mylan) (2024)– FDA label, DailyMed setid 2837a082-3a34-6f81-5e43-45a70295686b, version 17, revised 08/2024, Boxed Warning, Warnings (Hemorrhage), Precautions (Drug Interactions: Warfarin, Digoxin, Salicylate, and Heparin)