Non-selective NSAID Pregnancy: Contraindicated in pregnancy, labour and delivery, and during lactation (§4.3/§4.6) — risk of premature closure of the ductus arteriosus, oligohydramnios from gestational week 20 onward, renal dysfunction, prolonged bleeding time and inhibition of uterine contractions.

Ketorolac trometamol

Brand names: Toradol, Acuvail

Ketorolac trometamol is a potent parenteral NSAID used for the short-term management of moderate to severe acute pain, including postoperative and renal-colic pain.

Auto-extracted from the source labelling — not yet independently clinician-verified. These values were distilled from the UK SPC (or the US label where noted) but have not had a clinician sign-off. Confirm against the current SmPC before prescribing.

Adult dose

Dose: Initial dose 10 mg, followed by 10 to 30 mg every four to six hours as required

Route: Intramuscular or bolus intravenous injection (IV bolus given over no less than 15 seconds)

Frequency: Every 4 to 6 hours as required; in the initial post-operative period may be given as often as every 2 hours if needed

Max: Total daily dose of 90 mg (non-elderly) and 60 mg (elderly, renally-impaired patients and patients less than 50 kg) should not be exceeded; maximum duration of treatment 2 days

eMC §4.2 (Toradol 30 mg/ml solution for injection). Dosage should be adjusted according to the severity of the pain and the patient response, using the lowest effective dose for the shortest duration. Continuous multiple daily doses IM or IV should not exceed two days because adverse events may increase with prolonged usage. Reduce dosage in patients under 50 kg. Onset of analgesia approximately 30 minutes after IV or IM administration, maximum analgesia within 1–2 hours, median duration 4–6 hours. Opioid analgesics (e.g. morphine, pethidine) may be used concomitantly and may be required for optimal analgesia in the early post-operative period; the daily opioid dose required is usually less than normal. Must NOT be used for epidural, spinal or neuraxial (intrathecal) administration. Elderly have increased plasma half-life and reduced clearance — a longer dosing interval is advisable and total daily dose must not exceed 60 mg. Paediatric: safety and efficacy in children have not been established and ketorolac is not recommended, and is contraindicated, in children under 16 years of age (§4.2/§4.3).

Dose adjustments

Renal

Contraindicated in moderate to severe renal impairment (serum creatinine >160 micromol/L); reduce dosage in lesser impairment, not exceeding 60 mg/day IV or IM (§4.2/§4.3).

Dose auto-extracted from UK Summary of Product Characteristics (SPC) via the eMC — not yet clinician-verified. Always confirm against the product SmPC and your local formulary before prescribing.

Contraindications

Hypersensitivity to ketorolac, its excipients or other NSAIDs, and patients in whom aspirin or other prostaglandin synthesis inhibitors induce allergic reactions (asthma, rhinitis, angioedema, urticaria)
History of asthma; complete or partial syndrome of nasal polyps, angioedema or bronchospasm
Children under 16 years of age
Active peptic ulcer, or any history of gastrointestinal bleeding, ulceration or perforation
Severe heart failure, hepatic failure and renal failure; moderate or severe renal impairment (serum creatinine >160 micromol/L) or patients at risk of renal failure due to volume depletion or dehydration
Pregnancy, labour, delivery or lactation
Prophylactic analgesia before surgery and intra-operative use (inhibition of platelet aggregation / increased bleeding risk); suspected or confirmed cerebrovascular bleeding; operations with high risk of haemorrhage or incomplete haemostasis; haemorrhagic diatheses and coagulation disorders
Patients on anticoagulants including warfarin and low-dose heparin (2500–5000 units 12-hourly); patients currently receiving aspirin or other NSAIDs (including COX-2 selective inhibitors)
Concurrent oxpentifylline, probenecid or lithium salts
Neuraxial (epidural or intrathecal) administration, due to the alcohol content of the solution for injection

Side effects

Gastrointestinal — peptic ulcer, GI perforation or bleeding (sometimes fatal, particularly in the elderly), nausea, vomiting, diarrhoea, dyspepsia, abdominal pain, melaena, haematemesis
Renal — acute renal failure, interstitial nephritis, nephrotic syndrome, oliguria, urinary retention; elevations of creatinine and potassium can occur after a single dose
Haematological — thrombocytopenia, purpura, neutropenia, agranulocytosis, aplastic and haemolytic anaemia
Hypersensitivity — anaphylaxis and anaphylactoid reactions (may be fatal), bronchospasm, flushing, rash, hypotension, laryngeal oedema
Nervous system / psychiatric — headache, dizziness, convulsions, paraesthesia, drowsiness, abnormal thinking, insomnia, depression, hallucinations; cardiovascular — hypertension, hypotension, palpitations, bradycardia, cardiac failure, postoperative wound haemorrhage

Interactions

Anticoagulants including warfarin and low-dose heparin — contraindicated (§4.3)
Aspirin, other NSAIDs and COX-2 selective inhibitors — contraindicated concurrently (§4.3/§4.4)
Oxpentifylline — combination contraindicated (§4.3)
Probenecid and lithium salts — concurrent treatment contraindicated (§4.3)
Opioid analgesics may be used concomitantly; the daily opioid dose required is usually reduced (§4.2)
Full §4.5 interactions section was not captured in this bundle — clinician to review the SPC interactions section directly

Clinical monograph

How it works

It non-selectively inhibits cyclooxygenase, reducing prostaglandin synthesis to produce analgesic and anti-inflammatory effects.

Prescribing in practice

It carries a high risk of serious gastrointestinal bleeding and ulceration and of renal impairment, so it must be used at the lowest effective dose for the shortest possible time.
It is contraindicated in active peptic ulceration, significant renal impairment, bleeding disorders, hypovolaemia and around the time of major surgery with high bleeding risk.
It inhibits platelet function and should not be combined with other NSAIDs and used cautiously with anticoagulants.

Monitoring

Monitor renal function, blood pressure, fluid status and for signs of gastrointestinal or other bleeding during treatment.

Counselling the patient

This is a strong anti-inflammatory painkiller intended only for short-term use.
Report black stools, vomiting blood, indigestion or reduced urine output.
Do not take other anti-inflammatory medicines at the same time.

Evidence & guidelines

Restricted short-course use reflects MHRA and SPC warnings on NSAID gastrointestinal and renal risks.

Reference: MHRA; Drug verified in RxNorm (NLM); confirm dosing against the manufacturer SPC (eMC). Verify against your local formulary and current prescribing references before prescribing. The structured dose values shown have been reviewed by a clinician. Monograph status: clinician-reviewed (2026-07-04).

Curated clinical cross-links plus same-class fallbacks.

Drugs

Pathways

📚 MRCEM Revision

Featured in these MRCEM clinical pathways

Ketorolac trometamol is a core drug in the following exam-focused workups on our sister siteReviseMRCEM.

Renal Colic

MRCEM Primary / Intermediate / OSCE candidates: each pathway includes exam-style questions, RCEM/NICE citations, and FAQ summaries.