Ketorolac Tromethamine

A to Z Drug Facts

(KEY-TOR-oh-lak tro-METH-uh-meen)

Acular,  Toradol Toradol IM

Class: Analgesic/NSAID

 Action Decreases inflammation, pain and fever, probably through inhibition of cyclooxygenase activity and prostaglandin synthesis.

 Indications

Oral and intramuscular forms: Short-term management of pain. Ophthalmic form: Relief of ocular itching caused by seasonal allergic conjunctivitis.

 Contraindications Patients in whom aspirin, iodides or any NSAID has caused allergic-type reactions; active peptic ulcer disease, recent GI bleeding or perforation; advanced renal impairment and in patients at risk for renal failure due to volume depletion; suspected or confirmed cerebrovascular bleeding; hemorrhagic diathesis, incomplete hemostasis and those at high risk of bleeding; as prophylactic analgesia before any major surgery and intraoperatively when hemostasis is critical; for intrathecal or epidural administration due to its alcohol content; in labor and delivery; in lactation; in concomitant use with aspirin or other NSAIDs; concomitant use with probenecid.

Ophthalmic use: Soft contact lens use.

 Route/Dosage

Single dose

ADULTS: IM < 65 years old - 60 mg; > 65 years old, renal impairment or weight < 50 kg (110 lbs) - 30 mg. IV < 65 years old - 30 mg; > 65 years old, renal impairment or weight < 50 kg (110 lbs) - 15 mg.

Multiple dose

ADULTS: IM < 65 years old - 30 mg every 6 hours. Maximum daily dose should not exceed 120 mg; > 65 years old, renal impairment or weight < 50 kg (110 lbs) - 15 mg every 6 hours. Maximum daily dose should not exceed 60 mg.

Transition from IV/IM to oral

ADULTS: < 65 years old - 20 mg as a first oral dose for patients who received 60 mg IM single dose, 30 mg IV single dose or 30 mg multiple dose IV/IM, followed by 10 mg every 4 to 6 hours, not to exceed 40 mg/24 hours. > 65 years old, renal impairment or weight < 50 kg (110 lbs) - 10 mg as a first oral dose for patients who received a 30 mg IM single dose, 15 mg IV single dose or 15 mg multiple dose IV/IM, followed by 10 mg every 4 to 6 hours, not to exceed 40 mg/24 hours.

Ophthalmic

1 gtt qid.

 Interactions

Anticoagulants: May increase risk of gastric erosion and bleeding. Cyclosporine: Nephrotoxicity of both agents may be increased. Lithium: Serum lithium levels may be increased. Methotrexate: May increase methotrexate levels. Salicylates: May cause additive GI toxicity.

 Lab Test Interferences Drug may prolong bleeding time.

 Adverse Reactions

CV: Fluid retention; edema. CNS: Nervousness; abnormal thinking; depression; euphoria; headache; drowsiness; dizziness. DERM: Rash. EENT: Stomatitis. Ophthalmic use: Increased bleeding with ocular surgery; ocular irritation; allergic reactions; superficial keratitis. GI: Nausea; diarrhea; flatulence; GI fullness; abdominal distress; excessive thirst; GI toxicity. HEPA: Abnormal liver function test results. RESP: Bronchospasm. OTHER: Muscle cramps; aseptic meningitis.

 Precautions

Pregnancy: Category C. Lactation: Excreted in breast milk. Children: Safety and efficacy have not been established. Elderly patients: Increased risk of adverse reactions. Chronic use: Intramuscular drug is not intended for long-term use. Limit to short-term therapy (not > 5 days). Oral drug is intended for limited duration of use. GI effects: Serious GI toxicity (eg, bleeding, ulceration, perforation) can occur at any time with or without warning symptoms. Hypersensitivity: May occur; use drug with caution in aspirin-sensitive individuals because of possible cross-sensitivity. Photosensitivity: Drug can cause photosensitization. Renal effects: Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia and renal papillary necrosis may occur. Renal impairment: Assess function before and during therapy, because NSAID metabolites are eliminated renally. Dosage adjustments may be necessary.

 Administration/Storage

• The combined duration of ketorolac IV/IM and oral is not to exceed 5 days. Oral use is only indicated as continuation therapy to IV/IM.
• Do not mix IV/IM ketorolac in a small volume (eg, in a syringe) with morphine sulfate, meperidine HC1, promethazine HC1 or hydroxyzine HC1; this will result in precipitation of ketorolac from solution.
• When administering IM/IV, the IV bolus must be given over no less than 15 seconds. Give IM administration slowly and deeply into the muscle. The analgesic effect begins in 30 minutes with maximum effect in 1 to 2 hours after IV or IM dosing. Duration of the analgesic effect is usually 4 to 6 hours.
• If GI upset occurs, administer oral form with meals, milk or antacids to decrease GI irritation.
• With IM administration rotate injection sites.
• For ophthalmic administration, have patient tilt head back, instill drops into conjunctival sac and close eyes. Apply light finger pressure to lacrimal sac for 1 min after instillation. Do not touch top of cap to eye, fingers or other surface.
• Wash hands before and after instillation.
• Lower doses may be necessary in patients with compromised renal or hepatic function.
• Store at room temperature. Protect from light.

 Assessment/Interventions

• Obtain patient history, including drug history and any known allergies.
• Assess degree, location and type of pain before and after administration.
• With ophthalmic use, evaluate ocular itching before and after administration.
• Assess renal function before and during therapy. Monitor serum creatinine or creatinine clearance.
• Monitor for hematomas and bleeding, especially with perioperative intramuscular administration.
• Monitor liver function tests. Notify physician if abnormal liver function tests persist or worsen, if clinical signs and symptoms consistent with liver disease develop or if systemic mani Festations (eg, 5 osinophlia, rash) occur.
• Monitor patients with compromised cardiac function and hypertension for signs of fluid retention (eg, peripheral edema).
• Observe for signs of GI toxicity, especially in elderly patients.
• Observe for signs of infection because ketorolac may mask usual signs.
• Hypersensitivity reactions, ranging from bronchospasm to anaphylactic shock, have occurred, and appropriate counteractive measures must be available when administering the first dose of ketorolac.

 Patient/Family Education

• Instruct patient to take drug with food, milk or antacid if GI upset occurs.
• Inform patient that drug is NSAID and can cause serious side effects such as GI bleeding.
• Instruct patient to avoid alcohol, aspirin and other NSAIDs.
• Advise patient to inform dentist and other physicians of drug therapy before any treatment or surgery.
• Instruct patient to report these symptoms to physician: skin rash, itching, visual disturbances, weight gain, edema, black stools or persistent headache.
• Inform patient using ophthalmic solution not to wear soft contact lenses during treatment; ocular irritation with redness and burning can occur.
• Caution patient to avoid exposure to sunlight and other sources of UV light and to use sunscreen or wear protective clothing to avoid photosensitivity reaction.
• Advise patient that drug may cause drowsiness or dizziness and to use caution while driving or performing other tasks requiring mental alertness.
• Instruct patient not to take any otc medications without consulting physician.

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Copyright © 2003 Facts and Comparisons
David S. Tatro
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