Toradol

Toradol (ketorolac tromethamine) is a potent 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 administration—such as respiratory depression, sedation, and potential for misuse—must be mitigated. As a non-narcotic agent, Toradol provides powerful analgesia by inhibiting prostaglandin synthesis via cyclooxygenase (COX) enzyme inhibition, effectively reducing inflammation and pain at the site of injury. Its use is strictly limited to short-term therapy, typically not exceeding five days, due to the increased risk of serious adverse events with prolonged administration. This profile makes it an invaluable tool in post-operative care, renal colic, and other acute pain scenarios where rapid and effective pain control is paramount.

Features

• Active pharmaceutical ingredient: Ketorolac tromethamine.
• Pharmacologic class: Nonsteroidal anti-inflammatory drug (NSAID).
• Available formulations: Oral tablets (10 mg), intramuscular (IM) and intravenous (IV) injection (15 mg/mL, 30 mg/mL).
• Mechanism of action: Potent inhibitor of prostaglandin synthesis via non-selective cyclooxygenase (COX-1 and COX-2) enzyme inhibition.
• Onset of action: Analgesic effect begins within 30 minutes with IM/IV administration; within 30-60 minutes with oral administration.
• Peak plasma concentration: Achieved in approximately 30-50 minutes following IM injection.
• Duration of analgesic effect: 4-6 hours for a single dose.
• Half-life: Approximately 5-6 hours in adults with normal renal function.
• Metabolism: Primarily hepatic, via conjugation and glucuronidation.
• Excretion: Primarily renal (approximately 91% of a dose recovered in urine, 6% in feces).

Benefits

• Provides potent analgesia equivalent to certain opioid medications for many types of acute pain, without the associated risks of respiratory depression, significant sedation, or physical dependence.
• Offers a non-opioid alternative for pain management, which is crucial in the context of the opioid epidemic and for patients with a history of substance use disorder.
• Effective in reducing inflammation at the source of pain, addressing the underlying pathophysiology of many acute painful conditions, rather than merely masking the pain sensation.
• Rapid onset of action, particularly with parenteral administration, allows for quick control of severe pain in emergency and post-operative settings.
• Can be used as a component of multimodal analgesia, reducing the total dosage of opioids required and minimizing opioid-related side effects like nausea, vomiting, and constipation.

Common use

Toradol is rigorously 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 reserved for situations where non-NSAID therapy has proven inadequate or is not tolerated. The most frequent clinical applications include the management of post-operative pain following surgical procedures, providing effective relief that can facilitate earlier mobilization. It is also highly effective in treating acute musculoskeletal pain, such as flares of osteoarthritis or acute soft tissue injuries, and is a first-line agent for the pain associated with renal colic (kidney stones). Its use in migraine headaches is also well-documented. It is critical to emphasize that Toradol is not indicated for minor or chronic pain conditions, nor for prophylactic use or as an antipyretic (fever-reducer).

Dosage and direction

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

• Parenteral (IM/IV) Dosing (for initiation of therapy):

  • Single-Dose Treatment: 30 mg IM or 15 mg IV for patients with normal renal function.
  • Multiple-Dose Treatment: 30 mg IM/IV every 6 hours. Maximum daily dose: 120 mg.
  • For patients with renal impairment OR weight < 50 kg (110 lbs): Dose should be reduced. A common reduced dose is 15 mg IM/IV every 6 hours. Maximum daily dose: 60 mg.
  • Elderly patients (>65 years): Dosing must be conservative due to increased risk of adverse effects; consider the reduced dose of 15 mg every 6 hours.

• Oral Dosing (as continuation therapy following parenteral form):

  • The oral dose is only used as follow-up treatment to parenteral dosing.
  • Standard dose: 20 mg (two 10 mg tablets) as a first oral dose for patients who received a parenteral dose, followed by 10 mg every 4 to 6 hours as needed for pain.
  • Maximum daily oral dose: 40 mg.
  • The combined duration of parenteral and oral therapy must not exceed 5 days.

Direction: Tablets should be swallowed whole with a full glass of water. To minimize the risk of gastrointestinal upset, it should be taken with food or milk. Patients must use the lowest effective dose for the shortest possible duration.

Precautions

Extreme caution is warranted when prescribing Toradol due to its significant risk profile. It is contraindicated as a prophylactic analgesic before any major surgery and is not recommended for use during labor and delivery. Caution is advised in patients with a history of peptic ulcer disease or GI bleeding, as Toradol carries a high risk of causing serious GI adverse events. Use with extreme caution in patients with pre-existing renal impairment, volume depletion, heart failure, liver dysfunction, or coagulation disorders. Toradol can inhibit platelet aggregation; bleeding time is prolonged for 24-48 hours after discontinuation. Patients should be advised to report any signs of GI bleeding (e.g., black, tarry stools, vomiting blood), skin reactions, unexplained weight gain, or edema. Toradol should be avoided in late pregnancy as it may cause premature closure of the ductus arteriosus.

Contraindications

Toradol is absolutely contraindicated in the following scenarios:

• Known hypersensitivity (e.g., anaphylactic reactions, serious skin reactions) to ketorolac, any other NSAID, or aspirin.
• Active peptic ulcer disease, recent gastrointestinal bleeding or perforation.
• History of asthma, urticaria, or other allergic-type reactions after taking aspirin or other NSAIDs.
• As prophylactic analgesia before any major surgery.
• In the setting of coronary artery bypass graft (CABG) surgery.
• In patients with advanced renal impairment or patients at risk for renal failure due to volume depletion.
• Concurrent use with other NSAIDs (e.g., aspirin, ibuprofen, naproxen) or with probenecid or pentoxifylline.
• During the third trimester of pregnancy and in labor and delivery.
• In nursing mothers.

Possible side effect

Toradol use is associated with a high incidence of side effects, which is a primary reason for its short-term use limitation.

• Common (>1%): Nausea, dyspepsia, gastrointestinal pain, drowsiness, dizziness, headache, injection site pain (with IM formulation).
• Serious (require immediate medical attention):
  • Gastrointestinal: GI ulceration, bleeding, perforation, and hemorrhage, which can be fatal.
  • Cardiovascular: Hypertension, congestive heart failure, myocardial infarction, stroke.
  • Renal: Renal papillary necrosis, interstitial nephritis, acute renal failure, elevated BUN and serum creatinine.
  • Hematologic: Prolonged bleeding time, postoperative wound hemorrhage, thrombocytopenia.
  • Hepatic: Hepatitis, liver failure, jaundice.
  • Dermatologic: Stevens-Johnson Syndrome (SJS), Toxic Epidermal Necrolysis (TEN), exfoliative dermatitis.
  • Hypersensitivity: Anaphylaxis, angioedema, bronchospasm.

Drug interaction

Toradol has numerous clinically significant drug interactions that must be carefully managed:

• Other NSAIDs (including aspirin): Concurrent use is contraindicated due to additive risks of serious GI toxicity.
• Anticoagulants (e.g., warfarin) and Antiplatelets (e.g., clopidogrel): Increased risk of serious, potentially fatal bleeding due to additive effects on platelet function and the GI mucosa.
• Selective Serotonin Reuptake Inhibitors (SSRIs) and SNRIs: Increased risk of GI bleeding.
• ACE Inhibitors, ARBs, and Diuretics: Concomitant use may impair renal function and reduce the antihypertensive effect of these agents. Risk of acute renal failure is increased in volume-depleted patients.
• Lithium: Toradol can decrease renal clearance of lithium, leading to increased plasma lithium levels and potential toxicity.
• Methotrexate: Toradol may reduce the tubular secretion of methotrexate, increasing methotrexate plasma levels and the risk of toxicity.
• Probenecid: Concurrent use is contraindicated as it significantly increases ketorolac plasma levels and half-life.
• Pentoxifylline: Concurrent use is contraindicated due to an increased risk of bleeding.

Missed dose

As Toradol is prescribed on an as-needed basis for acute pain, the concept of a “missed dose” is not typically applicable in the same way as with chronic medications. The dosing is not scheduled around the clock. If a dose is needed for breakthrough pain and it is within the appropriate dosing interval (e.g., not sooner than 4-6 hours from the last oral dose), the patient may take it. They should not double the next dose to make up for a missed one.

Overdose

Overdose of Toradol can be very serious and may manifest as symptoms of significant NSAID overdose.

• Symptoms: Primarily includes nausea, vomiting, epigastric pain, gastrointestinal bleeding, lethargy, drowsiness, acute renal failure, respiratory depression, and coma. Hypertension, acute metabolic acidosis, and rarely, seizures may occur.
• Management: There is no specific antidote for ketorolac overdose. Management is supportive and symptomatic. Gastric lavage or administration of 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. Carefully monitor and support renal and hepatic function, and provide intensive supportive care for bleeding, hypertension, or respiratory depression.

Storage

• Store at room temperature between 20°C to 25°C (68°F to 77°F). Excursions are permitted between 15°C to 30°C (59°F to 86°F).
• Protect from light.
• Keep the medication in its original container, tightly closed.
• Keep out of 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 through a medicine take-back program or consult your pharmacist.

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 medication. Never disregard professional medical advice or delay in seeking it because of something you have read here. The author does not recommend or endorse any specific tests, physicians, products, procedures, opinions, or other information that may be mentioned. Reliance on any information provided here is solely at your own risk.

Reviews

• Clinical Consensus: Toradol is widely regarded by emergency medicine physicians, surgeons, and anesthesiologists as an exceptionally effective non-opioid analgesic for acute, severe pain. Its potency is frequently cited as its greatest strength.
• Expert Critique: The predominant theme in medical literature and expert review is the necessity of strict adherence to its short-term (5-day) dosing limit. Its significant risk profile for GI bleeding, renal impairment, and cardiovascular events is well-documented and is the primary factor limiting its use. It is considered a powerful tool that must be used with extreme caution and respect for its contraindications.
• Patient Feedback: Patient experiences often highlight its effectiveness in providing relief from severe pain, particularly post-operatively or from kidney stones. Common negative feedback revolves around side effects, most frequently gastrointestinal discomfort (nausea, upset stomach). The injectable form is frequently noted as being painful upon administration.