Ketorolac
Author: Dr. Wamiq Ansari
Last Updated:
Classification
1. Class: Non-Steroidal Anti-inflammatory Drug (NSAID).
2. Sub-class: Acetic Acid Derivative.
3. Type: Non-selective COX inhibitor.
Mechanism of Action
1. Inhibits COX-1 and COX-2.
2. Mainly acts as Analgesic.
Pharmacokinetics
1. Half Life: 4-10 hours.
2. Absorption: Rapidly absorbed (Peak plasma concentration 30-60 minutes (parenterally) and 1-2 hours (orally).
3. Metabolism: by Liver.
4. Excretion: Mainly in urine.
Indications
1. Short term Post-operative Pain management (preferred over Opioids due to no respiratory depression, sedation and dependence).
2. Ophthalmic Inflammations (allergic conjunctivitis or post-cataract surgery) .
Absolute Contraindications
1. Known Hypersensitivity.
3. Ongoing or previous history of Gastrointestinal Bleeding.
4. Bleeding disorders or thrombocytopenia.
4. Severe Renal Impairement.
5. Recent High risk surgery (Neurosurgery, cardiac surgery).
Relative Contraindications
1. Hypovolemia or dehydration.
2. History of NSAID-induced asthma or anaphylaxis.
3. Severe Hepatic impairement.
Dosage
Parenteral
| Age 2 years or more | 0.5 mg/kg/dose IV or IM x every 6-8 hours. |
Ophthalmic
| Seasonal Allergic Conjunctivitis | 1 drop of 0.5% formulation in each eye x every 6 hours for 4-5 days. |
| Post-cataract Surgery | 1 drop of 0.5% formulation in affected eye x every 6 hours for 2 weeks. (must be started after 24 hours of surgery) |
| Post-corneal refractive surgery | 1 drop of 0.4% formulation x every 6 hours for 4 days. |
Special Instructions
1. Must always be used in children with 2 years or more age.
2. Use of Ketorolac must not exceed 5 days due to higher risk of adverse effects.
Maximum Dosage
| Maximum Daily Dose | 60 mg/day. |
Special Instructions
1. Must always be used in children with 2 years or more age.
2. Use of Ketorolac must not exceed 5 days due to higher risk of adverse effects.
Method of IV Preparation
1. Dilute every 3mg of dose in 1 mL of 0.9% Normal Saline, Dextrose 5%, Dextrose 10% or Ringer Lactate.
2. Infuse over more than 10 minuted.
3. Avoid rapid rate of infusion.
Renal Adjustment Dosage
| Mild to Moderate Imparement (CrCl 30-60 mL/min) | Reduce dose by 50%. |
| Severe Imparement (CrCl less than 30 mL/min) | Contraindicated. |
Hepatic Adjustment Dosage
| Mild to Moderate Imparement | No adjustment needed. |
| Severe Imparement | 1. Avoid prolonged use. 2. Reduce dose by 50%. |
Adverse Effects
1. Gastrointestinal upset :
- a. Gastritis.
- b. Nausea, vomiting and abdominal pain.
- c. Long term use : Peptic ulcer disease, GI Bleeding or perforation.
2. Cardiovascular
- a. Hypertension.
- b. Increased risk of thrombotic events.
3. Renal
- a. Acute Kidney Injury.
- b. Interstitial Nephritis.
- c. Electrolyte Imbalances (Hyperkalemia, hyponatremia).
4. Hematologic
- a. Platelet aggregation (increased risk for bleeding).
- b. Aplastic Anemia (rare).
5. Hepatic
- a. Elevated Liver enzymes.
- b. Hepatic Failure (rare).
6. Nervous System
- a. Headache, dizziness and drowsiness.
- b. Seizures (at high doses).
5. Hypersensitivity Reactions
- a. Rash, pruritis and urticaria.
- b. Severe allergic reactions (Steven-Johnson Syndrome, toxic epidermal necrolysis or anaphylaxis).
Toxicity
1. No exact toxic dose.
2. Avoid doses more than 1gm per day
2. Findings :
- a. Gastrointestinal : Severe and persistent nausea, vomiting and abdominal pain and GI bleeding.
- b. Central Nervous System : Altered Conscious level and seizures.
- c. Cardiovascular : Hypo- or Hypertension, arrhythmias and heart failure.
- d. Metabolic : Metabolic Acidosis, hyperkalemia and Acute Kidney Injury.
2. Management :
- a. Supportive care : Airway management, fluid resuscitation, seizure management and vital monitoring.
- b. Activated Charcoal : if presents within 1-2 hours of ingestion.
- c. GI Protection : Parenteral PPIs or H2 blockers.
- d. Dialysis : Not effective due to high binding affinity for plasma proteins.
References
1. Vanderah, Todd W. Basic and Clinical Pharmacology 16th Edition. McGraw Hill Professional, 3 Nov. 2023.
2. Tripathi, K D. Essentials of Medical Pharmacology. New Delhi, Jaypee Brothers Medical Publishers (P) Ltd, 2015
3. The, et al. The Harriet Lane Handbook, 23 Edition: South Asia Edition - E-Book. Elsevier Health Sciences, 20 June 2023.
4. McNicol ED, Rowe E, Cooper TE. Ketorolac for postoperative pain in children. Cochrane Database Syst Rev. 2018 Jul 7;7(7):CD012294. doi: 10.1002/14651858.CD012294.pub2. PMID: 29981164; PMCID: PMC6513208.
5. Forrest JB, Heitlinger EL, Revell S. Ketorolac for postoperative pain management in children. Drug Saf. 1997 May;16(5):309-29. doi: 10.2165/00002018-199716050-00003. PMID: 9187531.
6. Isabelle Bindseil, Rhynn Soderstrom, Ryan Balmat. Evaluation of ketorolac ceiling dose effects in pediatric patients in the emergency department. The American Journal of Emergency Medicine. Volume 89. 2025. Pages 139-143. ISSN 0735-6757. https://doi.org/10.1016/j.ajem.2024.12.011..