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Bedside Snapshot
  • Parenteral NSAID used for short-term management of moderate-to-severe acute pain, often as an opioid-sparing agent in the ED and perioperative settings.
  • Analgesic efficacy is comparable to moderate doses of opioids for many acute pain indications (renal colic, MSK trauma, post-op pain), but without respiratory depression or sedation.
  • Adult IV/IM dosing (normal renal function, <65 years, ≥50 kg): 15–30 mg IV or 30–60 mg IM as a single dose; or 15–30 mg IV/IM every 6 hours as needed, not exceeding 120 mg/day and 5 days of therapy.
  • Adult reduced dosing (≥65 years, <50 kg, or renal impairment): 7.5–15 mg IV or 15–30 mg IM as a single dose; or 7.5–15 mg IV/IM every 6 hours as needed, not exceeding 60 mg/day.
  • Oral step-down (adults): 10–20 mg PO once after IV/IM, then 10 mg PO q4–6h PRN (max 40 mg/day), with total duration of any route not to exceed 5 days.
  • Onset of analgesia: Typically within 10–30 minutes IV/IM, with peak at ~1–2 hours; duration of effect is usually 4–6 hours.
  • Major risks: GI bleeding, renal injury (especially with hypovolemia or CKD), platelet inhibition with increased bleeding risk, and potential cardiovascular risk similar to other NSAIDs. Absolute no-go in advanced renal impairment, active GI bleed, recent high-risk surgery, or third-trimester pregnancy.
Brand & Generic Names
  • Generic Name: Ketorolac tromethamine
  • Brand Names: Toradol (IV/IM/PO), Acular (ophthalmic), multiple generics
Medication Class

Nonsteroidal anti-inflammatory drug (NSAID); potent non-opioid analgesic with minimal sedative effect

Pharmacology

Mechanism of Action:

  • Reversibly inhibits cyclooxygenase (COX-1 and COX-2), decreasing prostaglandin synthesis
  • Analgesic, anti-inflammatory, and antipyretic effects result from reduced peripheral and central prostaglandin-mediated sensitization of nociceptors
  • Inhibition of COX-1–mediated thromboxane A₂ production impairs platelet aggregation, increasing bleeding risk (particularly perioperatively or with other anticoagulants/antiplatelets)
  • Reduced renal prostaglandin synthesis can decrease afferent arteriolar vasodilation, lowering glomerular filtration pressure and precipitating acute kidney injury in susceptible patients (e.g., hypovolemia, CKD, heart failure)

Pharmacokinetics (IV/IM/PO):

  • Onset: IV – analgesia within ~10 minutes; IM – ~30–60 minutes; PO – 30–60 minutes
  • Peak Effect: ~1–2 hours after IV/IM/PO dosing
  • Duration of Effect: ~4–6 hours for a single dose
  • Absorption: Nearly complete after IM and PO administration; bioavailability orally ~100%
  • Distribution: ~99% protein bound; volume of distribution ~0.1–0.3 L/kg
  • Metabolism: Primarily hepatic via hydroxylation and conjugation to inactive metabolites
  • Elimination: ~90% excreted in urine (mostly as metabolites, ~6% unchanged); remainder via feces
  • Half-Life: ~5–6 hours in healthy adults; prolonged in renal impairment and the elderly
Indications
  • Short-term treatment of moderate-to-severe acute pain (e.g., renal colic, musculoskeletal trauma, post-op pain) where opioid-sparing analgesia is desired
  • Adjunct to opioids in multimodal analgesia protocols (ED, perioperative, ICU) to reduce opioid requirements
  • Off-label: headache/migraine, biliary colic, and other visceral pain syndromes, depending on institutional practice and patient risk profile
Dosing & Administration

Available Forms:

  • Injectable solution: 15 mg/mL, 30 mg/mL vials and prefilled syringes
  • Oral tablets: 10 mg (for step-down therapy after IV/IM)
  • Ophthalmic solution: 0.4%, 0.5% (Acular) – not covered in this ED/ICU reference

Dosing – Adults (Parenteral and Oral):

Population Route & Dose Frequency Max Dose / Duration
Adults <65 yrs, ≥50 kg, normal renal function 15–30 mg IV or 30–60 mg IM Once, or q6h PRN Max 120 mg/day; max 5 days total therapy
Adults ≥65 yrs, <50 kg, or renal impairment (mild–moderate) 7.5–15 mg IV or 15–30 mg IM q6h PRN Max 60 mg/day; max 5 days total therapy
Oral step-down after IV/IM (adults) 10–20 mg PO once, then 10 mg PO Every 4–6 hours PRN Max 40 mg/day PO; total IV/IM/PO ≤5 days
Single-dose "ceiling" IV/IM analgesia (common ED practice) 15 mg IV or 30 mg IM Single dose Higher parenteral doses (e.g., 30 mg IV or 60 mg IM) generally do not improve analgesia but increase adverse effects
Renal impairment (CrCl <30 mL/min) or advanced CKD Generally avoid parenteral ketorolac — Contraindicated in advanced renal impairment
5-Day Maximum: Total duration of ketorolac therapy (IV, IM, and/or PO combined) should not exceed 5 days due to increased risk of serious adverse events with prolonged use.
Contraindications

Absolute Contraindications:

  • Known hypersensitivity to ketorolac, other NSAIDs, or aspirin (e.g., NSAID-exacerbated respiratory disease)
  • Active peptic ulcer disease, recent GI bleeding or perforation, or history of NSAID-related GI bleeding
  • Advanced renal impairment or patients at risk for renal failure due to volume depletion
  • Perioperative use in CABG surgery; significant recent high-risk surgery with bleeding risk (e.g., neurosurgery, major trauma with uncontrolled hemorrhage)
  • Third-trimester pregnancy (risk of premature closure of ductus arteriosus and fetal renal injury)
  • Concomitant use with other NSAIDs or full-dose aspirin; ketorolac should not be used for more than 5 days total

Major Precautions:

  • Elderly patients: Higher risk of GI bleeding, renal injury, and cardiovascular events; use reduced dosing and shortest duration
  • Patients with CKD, heart failure, cirrhosis, or hypovolemia: Increased risk of renal hypoperfusion and AKI; avoid or use extreme caution
  • Concurrent anticoagulants, antiplatelets, SSRIs/SNRIs, or corticosteroids: Additive bleeding risk; monitor closely or choose alternatives
  • Asthma with nasal polyps or aspirin sensitivity: Risk of bronchospasm (AERD)
  • Volume-depleted trauma or sepsis patients: Avoid until hemodynamics and renal perfusion are stabilized
GI Bleeding Risk: Ketorolac can cause GI bleeding, ulceration, and perforation, which can be fatal. Elderly patients and those with history of peptic ulcer disease or GI bleeding are at greatest risk. Use the lowest effective dose for the shortest duration.
Renal Injury Risk: NSAIDs can cause acute kidney injury, especially in patients with CKD, heart failure, cirrhosis, hypovolemia, or concurrent use of ACE inhibitors/ARBs/diuretics. Avoid in advanced renal impairment (CrCl <30 mL/min).
Adverse Effects

Common:

  • Dyspepsia, abdominal pain, nausea, vomiting
  • Headache, dizziness, drowsiness
  • Injection site pain (IM) or burning (IV)

Serious:

  • GI bleeding, ulceration, and perforation (can be fatal)
  • Acute kidney injury, especially in hypovolemic or CKD patients
  • Prolonged bleeding time and post-operative bleeding
  • Anaphylaxis, bronchospasm, and angioedema in NSAID-sensitive individuals
  • Myocardial infarction and stroke risk with prolonged or high-dose NSAID therapy (extrapolated to ketorolac)
Special Populations

Elderly Patients (≥65 years):

  • Use reduced dosing: 7.5–15 mg IV or 15–30 mg IM q6h PRN
  • Maximum 60 mg/day (half the standard dose)
  • Higher risk of GI bleeding, renal injury, and cardiovascular events
  • Use shortest duration possible

Low Body Weight (<50 kg):

  • Use reduced dosing: 7.5–15 mg IV or 15–30 mg IM q6h PRN
  • Maximum 60 mg/day

Renal Impairment:

  • Mild-Moderate (CrCl 30–60 mL/min): Use reduced dosing with extreme caution; monitor renal function closely
  • Advanced (CrCl <30 mL/min): Contraindicated; avoid ketorolac
  • Dialysis: Contraindicated

Hepatic Impairment:

  • Use with caution in mild-moderate hepatic disease
  • Avoid in severe hepatic impairment or cirrhosis (increased bleeding risk, impaired drug clearance)

Pregnancy & Lactation:

  • First/Second Trimester: Avoid if possible; use only if benefits outweigh risks
  • Third Trimester: Contraindicated (risk of premature closure of ductus arteriosus, fetal renal injury, prolonged labor)
  • Lactation: Excreted in breast milk in small amounts; use with caution or consider alternatives

Pediatric:

  • Not recommended for routine use in pediatrics due to lack of safety data
  • Some institutions use limited single-dose ketorolac in older children/adolescents for specific indications
Monitoring

Clinical Monitoring:

  • Pain scores and functional improvement to assess efficacy
  • Signs of GI bleeding (melena, hematemesis, dropping Hgb/Hct) in at-risk patients
  • Bleeding and bruising, especially in perioperative or anticoagulated patients
  • Blood pressure and volume status in patients with cardiovascular disease

Laboratory Monitoring:

  • Renal function (serum creatinine, urine output), particularly in elderly, CKD, heart failure, or volume-depleted patients
  • Hemoglobin/hematocrit if GI bleeding is suspected
  • Baseline renal function before initiating therapy in at-risk patients
Clinical Pearls
Lower Dose, Same Effect: For many ED pain indications, 15 mg IV or 30 mg IM ketorolac provides comparable analgesia to higher doses. Avoid automatically giving 30 mg IV or 60 mg IM to reduce toxicity risk. The dose-response curve plateaus, so higher doses increase side effects without improving pain relief.
Not a Benign Drug: Think of ketorolac as a short course, high-potency NSAID – not a benign drug. Screen for renal disease, GI risk, and bleeding risk before ordering, even in the ED. Ask about CKD, recent GI bleeding, anticoagulants, and volume status before administration.
Coordinate with Surgery: In trauma or perioperative patients, coordinate with surgery/anesthesia teams regarding NSAID use. Ketorolac is often avoided in high-bleeding-risk procedures (neurosurgery, spinal surgery, major vascular cases, recent trauma with ongoing bleeding).
Multimodal Analgesia: Consider combining ketorolac with acetaminophen and local/regional anesthesia as part of multimodal analgesia to minimize opioid requirements. This approach is particularly effective for MSK injuries, post-op pain, and renal colic.
If Worried, Pick Something Else: If you're worried about kidneys or gut, pick a different analgesic – especially in older, septic, volume-depleted, or cirrhotic patients. Don't give ketorolac "just to try it" in high-risk patients. Use opioids, acetaminophen, or regional anesthesia instead.
Excellent for Renal Colic: Ketorolac is highly effective for renal colic and is often superior to opioids for this indication. The standard dose (15–30 mg IV) provides excellent analgesia without sedation or respiratory depression. Ensure adequate hydration and normal renal function first.
5-Day Hard Stop: The 5-day maximum duration is a hard stop, not a suggestion. After 5 days, the risk of serious GI and renal complications increases significantly. Transition to oral NSAIDs (if appropriate) or other analgesics before hitting the 5-day limit.
Platelet Effects Reversible: Unlike aspirin, ketorolac's antiplatelet effects are reversible and resolve within 24–48 hours after the last dose. However, this is still long enough to cause bleeding complications in the perioperative period, so coordinate with surgical teams.
References
  • 1. Mahmoodi, A. N., & Ghlichloo, I. (2024). Ketorolac. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK545172/
  • 2. Pfizer. (2024). Ketorolac tromethamine injection prescribing information. Pfizer Inc.
  • 3. Drugs.com. (2025). Ketorolac dosage guide. https://www.drugs.com/dosage/ketorolac.html
  • 4. Motov, S., Yasavolian, M., Likourezos, A., Pushkar, I., Hossain, R., & Drapkin, J. (2017). Comparison of intravenous ketorolac at three single-dose regimens for treating acute pain in the emergency department: A randomized controlled trial. Annals of Emergency Medicine, 70(2), 177–184. https://doi.org/10.1016/j.annemergmed.2016.10.014
  • 5. Pathan, S. A., Mitra, B., & Cameron, P. A. (2018). A systematic review and meta-analysis comparing the efficacy of nonsteroidal anti-inflammatory drugs, opioids, and paracetamol in the treatment of acute renal colic. European Urology, 73(4), 583–595. https://doi.org/10.1016/j.eururo.2017.11.001
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