Toradol: Potent Non-Opioid Pain Relief for Acute Conditions
Toradol (ketorolac tromethamine) is a nonsteroidal anti-inflammatory drug (NSAID) indicated for the short-term management of moderately severe acute pain that requires analgesia at the opioid level. As a potent analgesic with anti-inflammatory and antipyretic properties, it offers a critical therapeutic option in clinical settings where opioid-sparing regimens are desired or necessary. Its efficacy profile makes it a valuable tool for physicians managing postoperative pain, renal colic, and musculoskeletal trauma, providing significant relief without the respiratory depression or high abuse potential associated with opioid analgesics. This product card provides a comprehensive, evidence-based overview for healthcare professionals considering its appropriate use.
Features
- Active Ingredient: Ketorolac tromethamine
- Pharmacologic Class: Nonsteroidal anti-inflammatory drug (NSAID)
- Available Formulations: Oral tablets, intramuscular (IM) injection, intravenous (IV) injection
- Mechanism of Action: Potent inhibitor of prostaglandin synthesis via cyclooxygenase (COX-1 and COX-2) enzyme inhibition
- Onset of Action: IM/IV: within 30 minutes; Oral: within 60 minutes
- Peak Plasma Concentration: IM: 50 minutes; Oral: 30–60 minutes
- Duration of Analgesic Effect: 4–6 hours
- Elimination Half-life: 5–6 hours in adults with normal renal function
- Protein Binding: 99%
- Metabolism: Primarily hepatic via glucuronidation and hydroxylation
- Excretion: Primarily renal (91%) with fecal elimination accounting for approximately 6%
Benefits
- Delivers potent analgesia comparable to certain opioids (e.g., 30mg IM ketorolac ≈ 12mg IM morphine) for acute pain without opioid-related side effects
- Reduces or eliminates the need for opioid analgesics in appropriate patients, decreasing risks of respiratory depression, sedation, and dependence
- Provides anti-inflammatory activity in addition to pain relief, addressing the underlying pathophysiology in many acute painful conditions
- Suitable for use in a wide range of clinical settings including emergency departments, postoperative recovery, and outpatient management
- Available in multiple formulations allowing for flexible dosing strategies including transition from parenteral to oral therapy
- Rapid onset of action provides timely relief for patients experiencing moderate to severe acute pain
Common use
Toradol is specifically indicated for the short-term management of moderately severe acute pain. Its use is typically reserved for situations where non-NSAID analgesia is insufficient and where opioid-level analgesia would otherwise be required. Common clinical applications include management of postoperative pain following surgical procedures, particularly when an opioid-sparing approach is desired. It is frequently employed for pain associated with acute musculoskeletal injuries including fractures, sprains, and strains. In emergency medicine, it is commonly used for renal colic pain, often demonstrating particular efficacy in this setting. Other appropriate uses include pain management for acute flares of chronic conditions such as gout or acute bursitis when other NSAIDs have proven inadequate. It is important to note that Toradol is not indicated for minor pain, chronic pain conditions, or prophylactic analgesic use.
Dosage and direction
Dosing must be individualized based on the patient’s pain severity, renal function, age, weight, and overall risk profile. For adults under 65 years with normal renal function: The recommended IM/IV dose is 30 mg as a single dose or 30 mg every 6 hours, not to exceed 120 mg daily. The maximum duration of parenteral therapy is 5 days. For conversion to oral therapy: 20 mg as first oral dose for patients who received single-dose parenteral therapy, followed by 10 mg every 4–6 hours as needed for pain, not to exceed 40 mg daily. For patients receiving multiple-dose parenteral therapy, the total combined duration of parenteral and oral therapy should not exceed 5 days. For patients over 65 years, those with renal impairment, or those weighing less than 50 kg (110 lbs): Reduce dose to 15 mg IM/IV every 6 hours, not to exceed 60 mg daily; oral dose should be reduced to 10 mg every 4–6 hours, not to exceed 40 mg daily. Toradol should be administered with food or milk to minimize gastrointestinal upset. The lowest effective dose should be used for the shortest duration possible.
Precautions
Toradol carries a significant risk of serious adverse effects requiring careful patient selection and monitoring. Gastrointestinal Risk: NSAIDs including Toradol can cause serious GI adverse events including bleeding, ulceration, and perforation, which can be fatal. These events can occur at any time during use and without warning symptoms. Cardiovascular Risk: NSAIDs may increase the risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke, which can be fatal. This risk may increase with duration of use and in patients with cardiovascular disease or risk factors. Renal Risk: Long-term administration of NSAIDs has resulted in renal papillary necrosis and other renal injury. Use with caution in patients with impaired renal function, heart failure, liver dysfunction, those taking diuretics or ACE inhibitors, and the elderly. Hematological Risk: NSAIDs inhibit platelet aggregation and may prolong bleeding time. Use with caution in patients with coagulation disorders. Hepatic Effects: Borderline elevations of liver tests may occur in up to 15% of patients. Pregnancy and Lactation: Should be avoided during late pregnancy due to risk of premature closure of ductus arteriosus; not recommended during breastfeeding.
Contraindications
Toradol is contraindicated in patients with known hypersensitivity to ketorolac tromethamine, aspirin, or other NSAIDs. It is contraindicated in patients with active peptic ulcer disease, recent gastrointestinal bleeding or perforation, or history of peptic ulcer disease or gastrointestinal bleeding. It should not be used in patients with advanced renal impairment or in patients at risk for renal failure due to volume depletion. Toradol is contraindicated as prophylactic analgesia before major surgery and intraoperatively when hemostasis is critical. It is contraindicated in patients with suspected or confirmed cerebrovascular bleeding, hemorrhagic diathesis, incomplete hemostasis, and those at high risk of bleeding. Concurrent use with other NSAIDs, including aspirin, is contraindicated. It is contraindicated during labor and delivery and in nursing mothers. Toradol is contraindicated for neuraxial (epidural or intrathecal) administration.
Possible side effect
The most frequently reported adverse reactions (occurring in >5% of patients) include gastrointestinal effects: nausea (12%), dyspepsia (12%), gastrointestinal pain (13%). Other common side effects include headache (17%), dizziness (7%), and drowsiness (6%). Serious side effects requiring immediate medical attention include: gastrointestinal bleeding, ulceration, or perforation; cardiovascular thrombotic events; renal toxicity (elevated BUN, creatinine, acute renal failure); hepatotoxicity (elevated liver enzymes, jaundice); severe skin reactions (Stevens-Johnson syndrome, toxic epidermal necrolysis); anaphylactoid reactions; and hematological effects (prolonged bleeding time, thrombocytopenia). Less common but significant effects include heart failure, hypertension, and fluid retention. Psychiatric effects including depression and abnormal thinking have been reported. The risk of serious adverse events increases with higher doses and longer duration of therapy.
Drug interaction
Toradol has numerous clinically significant drug interactions. Anticoagulants: Concurrent use with warfarin, heparin, or other anticoagulants increases risk of serious bleeding. Other NSAIDs: Concomitant use with aspirin or other NSAIDs increases risk of GI toxicity with no therapeutic advantage. ACE inhibitors/ARBs: May diminish antihypertensive effect and increase risk of renal impairment. Diuretics: NSAIDs may reduce the natriuretic effect of furosemide and thiazides. Lithium: Toradol may decrease lithium clearance, increasing lithium plasma levels and risk of toxicity. Methotrexate: May decrease methotrexate clearance, increasing toxicity risk. Selective serotonin reuptake inhibitors (SSRIs): Concurrent use may increase risk of bleeding. Cyclosporine: May increase risk of nephrotoxicity. Pemetrexed: May decrease pemetrexed clearance, increasing hematologic and renal toxicity. Probenecid: May increase ketorolac plasma levels. Close monitoring and dose adjustments are necessary when these combinations cannot be avoided.
Missed dose
As Toradol is prescribed for acute pain management on an as-needed basis, the concept of “missed dose” does not typically apply in the same manner as with chronic medications. If a dose is missed and pain returns, the next dose may be taken as soon as possible. However, patients should not double the next dose to make up for a missed one. The recommended dosing interval (every 4-6 hours for oral formulation) should be maintained to avoid exceeding the maximum daily dose. For scheduled postoperative pain management in inpatient settings, healthcare providers should follow institutional protocols for missed doses, typically administering the missed dose if remembered within a reasonable time frame, then resuming the regular schedule.
Overdose
Ketorolac overdose may manifest as symptoms including lethargy, drowsiness, nausea, vomiting, epigastric pain, gastrointestinal bleeding, coma, seizures, hypotension, acute renal failure, and respiratory depression. There is no specific antidote for ketorolac overdose. Management should be supportive and symptomatic. Gastric lavage or activated charcoal may be considered if ingestion was recent. Forced diuresis, alkalinization of urine, hemodialysis, or hemoperfusion may not be useful due to high protein binding. Carefully monitor renal and hepatic function, coagulation parameters, and cardiopulmonary status for several days after overdose. Symptomatic treatment for specific manifestations should be instituted promptly. In cases of significant gastrointestinal bleeding, appropriate measures including blood transfusion may be required.
Storage
Store Toradol tablets at controlled room temperature 20°-25°C (68°-77°F) in a tight, light-resistant container. Keep away from excessive moisture and heat. Parenteral formulations should be stored at controlled room temperature and protected from light. Do not freeze. Keep all medications out of reach of children and pets. Do not use beyond the expiration date printed on the packaging. Properly discard any unused medication after the prescribed treatment course is completed, as Toradol is not intended for long-term use. Do not flush medications down the toilet or pour them into a drain unless instructed to do so. Consult your pharmacist or local waste disposal company for proper disposal methods.
Disclaimer
This information is intended for healthcare professionals and should not replace 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. Never disregard professional medical advice or delay in seeking it because of something you have read in this product card. The content provided is for informational purposes only and reflects information available at the time of publication. Dosage indications, contraindications, and safety information may change as new research becomes available. Healthcare providers should consult the most current prescribing information before administering any medication.
Reviews
Clinical Evidence Summary: Multiple randomized controlled trials and meta-analyses support the efficacy of Toradol for acute pain management. A comprehensive review of 49 studies involving over 5,000 patients found that ketorolac 30mg IM provided analgesia equivalent to morphine 10-12mg IM for postoperative pain, with significantly less sedation and nausea. Another systematic review specifically examining renal colic pain management concluded that ketorolac provided superior analgesia to opioids with fewer adverse effects. However, recent large-scale observational studies have reinforced the significant safety concerns, particularly regarding gastrointestinal and cardiovascular risks, leading to more restrictive use guidelines. The consensus among pain specialists emphasizes that Toradol remains a valuable tool when used appropriately in selected patients for short durations, but requires careful risk-benefit assessment before prescription.
Expert Consensus: The American Pain Society guidelines include ketorolac as a recommended option for multimodal postoperative pain management. The American College of Emergency Physicians clinical policy gives ketorolac a Level A recommendation for renal colic pain management. However, most guidelines emphasize strict adherence to recommended dosing limits and treatment duration due to safety concerns. Many institutions have implemented protocols restricting ketorolac use to specific clinical scenarios and requiring renal function assessment before administration in at-risk patients.