ketorolac

Contraindicated in:

Hypersensitivity;
Cross-sensitivity with other NSAIDs may exist;
Preoperative use;
Active or history of peptic ulcer disease or GI bleeding;
Known alcohol intolerance (injection only);
Coronary artery bypass graft surgery;
Recent MI;
HF;
Cerebrovascular bleeding;
Advanced renal impairment or at risk for renal failure due to volume depletion;
Concurrent use of pentoxifylline or probenecid;
OB: Avoid use of after 30 wk gestation; may inhibit labor and ↑ maternal bleeding at delivery.

Use Cautiously in:

Cardiovascular disease or risk factors for cardiovascular disease (may ↑ risk of serious cardiovascular thrombotic events, MI, and stroke, especially with prolonged use or use of higher doses);
History of long duration of NSAID use, smoking, alcohol use, advanced liver disease, coagulopathy, or poor general health (↑ risk of GI bleeding);
History of peptic ulcer disease and/or GI bleeding;
Bleeding tendency or concurrent anticoagulant therapy;
Mild to moderate renal impairment (↓ dose may be required);
Hepatic impairment;
OB: Use at or after 20 wk gestation may cause fetal or neonatal renal impairment; if treatment is necessary between 20 wk and 30 wk gestation, limit use to the lowest effective dose and shortest duration possible;
Lactation: Use while breastfeeding only if potential maternal benefit justifies potential risk to infant;
Pedi: Safety and effectiveness not established in neonates;
Geri: Appears on Beers list. ↑ risk of GI bleeding or peptic ulcer disease in older adults. Avoid chronic use unless other alternatives are not effective and the patient can take a gastroprotective agent; avoid short-term use in combination with oral or parenteral corticosteroids, anticoagulants, or antiplatelet agents unless other alternatives are not effective and the patient can take a gastroprotective agent.

Adv. Reactions/Side Effects ⬆ ⬇

Derm: ↑sweating, DRUG REACTION WITH EOSINOPHILIA AND SYSTEMIC SYMPTOMS (DRESS), EXFOLIATIVE DERMATITIS, GENERALIZED BULLOUS FIXED DRUG ERUPTION, pruritus, purpura, rash, STEVENS-JOHNSON SYNDROME (SJS), TOXIC EPIDERMAL NECROLYSIS (TEN), urticaria

EENT: ↑lacrimation (nasal spray), nasal discomfort (nasal spray), throat irritation (nasal spray)

F and E: hyperkalemia

GI: ↑liver enzymes, abdominal pain, abnormal taste, diarrhea, dry mouth, dyspepsia, GI BLEEDING, GI PERFORATION, GI ULCERATION, nausea

GU: oliguria, renal toxicity, urinary frequency

Hemat: prolonged bleeding time

Local: injection site pain

Neuro: drowsiness, abnormal thinking, dizziness, euphoria, headache, paresthesia, STROKE

Resp: asthma, dyspnea

Misc: HYPERSENSITIVITY REACTIONS (INCLUDING ANAPHYLAXIS AND SERIOUS SKIN REACTIONS)

Interactions ⬆ ⬇

Drug-drug:

Probenecid↑ levels and risk of toxicity; concurrent use contraindicated.
↑risk of bleeding with pentoxifylline; concurrent use contraindicated.
Aspirin may ↓ effectiveness.
↑risk of GI bleeding with anticoagulants, aspirin, clopidogrel, ticagrelor, prasugrel, corticosteroids, fibrinolytics, SNRIs, or SSRIs.
May ↓ effectiveness of diuretics or antihypertensives.
May ↑ levels and risk of toxicity of lithium.
May ↑ levels and risk of toxicity of methotrexate.
↑risk of adverse hematologic reactions with antineoplastics or radiation therapy.
May ↑ risk of nephrotoxicity from cyclosporine.

Drug-Natural Products:

↑bleeding risk with arnica, chamomile, clove, dong quai, feverfew, garlic, ginger, ginkgo, or Panax ginseng.

Availability ⬆ ⬇

(Generic available)

Tablets: 10 mg
Nasal spray (Sprix): 15.75 mg/spray in 1.7-g bottle (delivers 8 sprays)
Solution for injection: 15 mg/mL; 30 mg/mL

Route/Dosage ⬆ ⬇

Oral therapy is indicated only as a continuation of parenteral therapy. Total duration of therapy by all routes should not exceed 5 days.
PO (Adults <65 yr): 20 mg initially, followed by 10 mg every 4–6 hr (not to exceed 40 mg/day).
PO (Adults ≥65 yr, <50 kg, or with renal impairment): 10 mg every 4–6 hr (not to exceed 40 mg/day).
PO (Children 2–16 yr, <50 kg): 1 mg/kg as a single dose. No data available for multiple doses.
IM (Adults <65 yr): Single dose: 60 mg. Multiple dosing: 30 mg every 6 hr (not to exceed 120 mg/day).
IM (Adults ≥65 yr, <50 kg, or with renal impairment): Single dose: 30 mg. Multiple dosing: 15 mg every 6 hr (not to exceed 60 mg/day).
IM (Children 2–16 yr, <50 kg): Single dose: 0.4–1 mg/kg (maximum: 30 mg/dose). Multiple dosing: 0.5 mg/kg every 6 hr.
IV (Adults <65 yr): Single dose: 30 mg. Multiple dosing: 30 mg every 6 hr (not to exceed 120 mg/day).
IV (Adults ≥65 yr, <50 kg, or with renal impairment): Single dose: 15 mg. Multiple dosing: 15 mg every 6 hr (not to exceed 60 mg/day).
IV (Children 2–16 yr, <50 kg): Single dose: 0.4–1 mg/kg (maximum: 15 mg/dose). Multiple dosing: 0.5 mg/kg every 6 hr.
(Adults <65 yr): One spray in each nostril every 6–8 hr (not to exceed 4 sprays in each nostril/day).
(Adults ≥65 yr, <50 kg, or with renal impairment): One spray in only one nostril every 6–8 hr (not to exceed 4 sprays in one nostril/day).

US Brand Names ⬆ ⬇

Action ⬆ ⬇

Inhibits prostaglandin synthesis, producing peripherally mediated analgesia.
Also has antipyretic and anti-inflammatory properties.

Therapeutic effects:

Decreased pain.

Classifications ⬆ ⬇

Therapeutic Classification: nonopioid analgesics

Pharmacologic Classification: nonsteroidal anti inflammatory drugs nsaids

Pharmacokinetics ⬆ ⬇

Absorption: Rapidly and completely absorbed following all routes of administration.

Distribution: Well distributed to tissues.

Protein Binding: 99%.

Metabolism/Excretion: Primarily metabolized by the liver. Primarily excreted by the kidneys (92%); 6% excreted in feces.

Half-Life: 4.5 hr (range 3.8–6.3 hr; ↑ in older adults and patients with renal impairment).

Canadian Brand Names ⬆ ⬇

Time/Action Profile ⬆ ⬇

(analgesic effects)

ROUTE	ONSET	PEAK	DURATION
PO	unknown	2–3 hr	4–6 hr or longer
IM, IV	10 min	1–2 hr	6 hr or longer
IN	unknown	unknown	6–8 hr or longer

Patient/Family Teaching ⬆ ⬇

Explain purpose and side effects of medication. Advise patient to read Patient Information before starting therapy.
Instruct patient to take missed doses as soon as remembered if not almost time for next dose. Do not double doses. Do not take more than prescribed or for >5 days. Advise patient to notify health care provider of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health care provider before taking other medications, especially the concurrent use of alcohol, aspirin, NSAIDs, or acetaminophen.
- May cause drowsiness or dizziness. Advise patient to avoid driving or other activities requiring alertness until response to the medication is known.
- Advise patient to inform health care provider of medication regimen prior to treatment or surgery.
- Inform patient of ↑ risk of MI and stroke. Use lowest effective dose for shortest time. Advise patient to notify health care provider immediately if signs and symptoms (shortness of breath or trouble breathing, chest pain, weakness in one part or side of body, slurred speech, swelling of the face or throat) occur.
- Advise patient to notify health care provider promptly if signs or symptoms of GI toxicity (abdominal pain, black stools) occur.
- Inform patient to discontinue ketorolac and notify health care provider if signs and symptoms of hepatotoxicity (nausea, fatigue, lethargy, diarrhea, pruritus, jaundice, abdominal pain, flu-like symptoms) occur.
- Advise patient to consult health care provider if rash, visual disturbances, tinnitus, weight gain, edema, persistent headache, chills, fever, or muscle aches occurs.
- May cause fetal harm. Advise women of reproductive potential to notify health care provider if pregnancy is planned or suspected or if breastfeeding. Advise pregnant patients to avoid ketorolac in the 3rd trimester of pregnancy (after 29 wk); may cause premature closure of fetal ductus arteriosus. Use of ketorolac after 20 wk may cause fetal renal impairment leading to oligohydramnios. Avoid use of ketorolac in labor and delivery; may adversely affect fetal circulation and inhibit uterine contractions. The risk of uterine hemorrhage may be ↑. May cause reversible infertility in women attempting to conceive.

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Indications ⬇

Contraind./Precautions ⬆ ⬇