Toradol


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ketorolac†

(kee-toe-role-ak) ,

Sprix

(trade name),

Toradol

(trade name)

Classification

Therapeutic: nonsteroidal anti inflammatory agents
Pharmacologic: pyrroziline carboxylic acid
Pregnancy Category: C (oral, nasal spray [<30 wk gestation])
Pregnancy Category: D (nasal spray [≥30 wk gestation)
†See for ophthalmic use

Indications

Short-term management of pain (not to exceed 5 days total for all routes combined).

Action

Inhibits prostaglandin synthesis, producing peripherally mediated analgesia.
Also has antipyretic and anti-inflammatory properties.

Therapeutic effects

Decreased pain.

Pharmacokinetics

Absorption: Rapidly and completely absorbed following all routes of administration.
Distribution: Enters breast milk in low concentrations.
Protein Binding: 99%.
Metabolism and Excretion: Primarily metabolized by the liver. Ketorolac and its metabolites are excreted primarily by the kidneys (92%); 6% excreted in feces.
Half-life: 4.5 hr (range 3.8–6.3 hr; ↑ in geriatric patients and patients with impaired renal function).

Time/action profile (analgesic effects)

ROUTEONSETPEAKDURATION
POunknown2–3 hr4–6 hr or longer
IM, IV10 min1–2 hr6 hr or longer
INunknownunknown6–8 hr or longer

Contraindications/Precautions

Contraindicated in: Hypersensitivity;Cross-sensitivity with other NSAIDs may exist;Preoperative use;Active or history of peptic ulcer disease or GI bleeding;Known alcohol intolerance (injection only);Perioperative pain from coronary artery bypass graft (CABG) surgery;Cerebrovascular bleeding;Advanced renal impairment or at risk for renal failure due to volume depletion;Concurrent use of pentoxifylline or probenecid; Obstetric: Chronic use in 3rd trimester may cause constriction of ductus arteriosus. May inhibit labor and ↑ maternal bleeding at delivery.
Use Cautiously in: Cardiovascular disease or risk factors for cardiovascular disease (may ↑ risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke, especially with prolonged use);Heart failure;Coagulation disorders;Mild-to-moderate renal impairment (dosage reduction may be required);Hepatic impairment; Pediatric: Safety not established in neonates; Geriatric: Appears on Beers list; ↑ risk of GI bleeding. Lactation: Lactation.

Adverse Reactions/Side Effects

Central nervous system

  • stroke (life-threatening)
  • drowsiness (most frequent)
  • abnormal thinking
  • dizziness
  • euphoria
  • headache

Ear, Eye, Nose, Throat

  • ↑ lacrimation (spray)
  • nasal discomfort (spray)
  • throat irritation (spray)

Respiratory

  • asthma
  • dyspnea

Cardiovascular

  • myocardial infarction (life-threatening)
  • edema
  • pallor
  • vasodilation

Gastrointestinal

  • gi bleeding (life-threatening)
  • abnormal taste
  • diarrhea
  • dry mouth
  • dyspepsia
  • GI pain
  • ↑ liver enzymes
  • nausea

Genitourinary

  • oliguria
  • renal toxicity
  • urinary frequency

Dermatologic

  • exfoliative dermatitis (life-threatening)
  • stevens-johnson syndrome (life-threatening)
  • toxic epidermal necrolysis (life-threatening)
  • pruritus
  • purpura
  • sweating
  • urticaria

Hematologic

  • prolonged bleeding time

Local

  • injection site pain

Neurologic

  • paresthesia

Miscellaneous

  • allergic reactions including
  • anaphylaxis (most frequent)

Interactions

Drug-Drug interaction

Probenecid ↑ levels and the risk of adverse reactions; concurrent use is contraindicated.↑ risk of bleeding when used with pentoxifylline ; concurrent use is contraindicated.Concurrent use with aspirin may ↓ effectiveness.↑ adverse GI effects with aspirin, other NSAIDs, potassium supplements, corticosteroids, or alcohol.May ↓ effectiveness of diuretics or antihypertensives.May ↑ serum lithium levels and ↑ risk of toxicity.↑ risk of toxicity from methotrexate.↑ risk of bleeding with cefotetan, cefoperazone, valproic acid, clopidogrel, ticlopidine, tirofiban, eptifibatide, thrombolytic agents, or anticoagulants.↑ risk of adverse hematologic reactions with antineoplastics or radiation therapy.May ↑ risk of nephrotoxicity from cyclosporine.↑ bleeding risk with arnica, chamomile, clove, dong quai, feverfew, garlic, ginger, ginkgo, Panax ginseng.

Route/Dosage

Oral therapy is indicated only as a continuation of parenteral therapy. Total duration of therapy by all routes should not exceed 5 days
Oral (Adults <65 yr) 20 mg initially, followed by 10 mg q 4–6 hr (not to exceed 40 mg/day).
Oral (Adults ≥65 yr, <50 kg, or with renal impairment) 10 mg q 4–6 hr (not to exceed 40 mg/day).
Oral (Children 2–16 yr, <50 kg) 1 mg/kg as a single dose. No data available for multiple doses.
Intramuscular (Adults <65 yr) Single dose—60 mg. Multiple dosing—30 mg q 6 hr (not to exceed 120 mg/day).
Intramuscular (Adults ≥65 yr, <50 kg, or with renal impairment) Single dose—30 mg. Multiple dosing—15 mg q 6 hr (not to exceed 60 mg/day).
Intramuscular (Children 2–16 yr, <50 kg) Single dose—0.4–1 mg/kg (maximum: 30 mg/dose). Multiple dosing—0.5 mg/kg q 6 hr.
Intravenous (Adults <65 yr) Single dose—30 mg. Multiple dosing—30 mg q 6 hr (not to exceed 120 mg/day).
Intravenous (Adults ≥65 yr, <50 kg, or with renal impairment) Single dose—15 mg. Multiple dosing—15 mg q 6 hr (not to exceed 60 mg/day).
Intravenous (Children 2–16 yr, <50 kg) Single dose—0.4–1 mg/kg (maximum: 15 mg/dose). Multiple dosing—0.5 mg/kg q 6 hr.
Intranasal (Adults <65 yr) 1 spray in each nostril q 6–8 hr (not to exceed 4 sprays in each nostril/day).
Intranasal (Adults ≥65 yr, <50 kg, or with renal impairment) 1 spray in only one nostril q 6–8 hr (not to exceed 4 sprays in one nostril/day).

Availability (generic available)

Tablets: 10 mg
Injection: 15 mg/mL, 30 mg/mL
Nasal spray (Sprix): 15.75 mg/spray in 1.7–g bottle (delivers 8 sprays)

Nursing implications

Nursing assessment

  • Patients who have asthma, aspirin-induced allergy, and nasal polyps are at increased risk for developing hypersensitivity reactions. Assess for rhinitis, asthma, and urticaria.
  • Assess for rash periodically during therapy. May cause Stevens-Johnson syndrome or toxic epidermal necrolysis. Discontinue therapy if severe or if accompanied with fever, general malaise, fatigue, muscle or joint aches, blisters, oral lesions, conjunctivitis, hepatitis and/or eosinophilia.
  • Pain: Assess pain (note type, location, and intensity) prior to and 1–2 hr following administration.
  • Lab Test Considerations: Evaluate liver function tests, especially AST and ALT, periodically in patients receiving prolonged therapy. May cause ↑ levels.
    • May cause prolonged bleeding time that may persist for 24–48 hr following discontinuation of therapy.
    • May cause ↑ BUN, serum creatinine, or potassium concentrations.

Potential Nursing Diagnoses

Acute pain (Indications)

Implementation

  • Do not confuse Toradol (ketorolac) with tramadol (Ultram).
    • Administration in higher-than-recommended doses does not provide increased effectiveness but may cause increased side effects. Duration of ketorolac therapy, by all routes combined, should not exceed 5 days. Use lowest effective dose for shortest period of time.
    • Coadministration with opioid analgesics may have additive analgesic effects and may permit lower opioid doses.
  • Oral: Ketorolac therapy should always be given initially by the IM or IV route. Use oral therapy only as a continuation of parenteral therapy.
  • Intravenous Administration
  • Administer undiluted. Concentration: 15–30 mg/mL.
  • Rate: Administer over at least 15 sec.
  • Y-Site Compatibility: alfentanil, amikacin, aminophylline, amphotericin B lipid complex, amphotericin B liposome, anidulafungin, argatroban, ascorbic acid, atracurium, atropine, aztreonam, benztropine, bivalirudin, bleomycin, bumetanide, buprenorphine, butorphanol, carboplatin, carmustine, cefazolin, cefoperazone, cefotaxime, cefotetan, cefoxitin, ceftazidime, ceftriaxone, cefuroxime, chloramphenicol, cisatracurium, cisplatin, clindamycin, cyanocobalamin, cyclophosphamide, cyclosporine, cytarabine, dactinomycin, daptomycin, dexamethasone, dexmedetomidine, digoxin, docetaxel, dopamine, doxacurium, doxorubicin hydrochloride, enalaprilat, ephedrine, epinephrine, epoetin alfa, eftifibatide, ertapenem, etoposide, etoposide phosphate, famotidine, fentanyl, fluconazole, fludarabine, fluorouracil, folic acid, furosemide, gentamicin, glycopyrrolate, granisetron, heparin, hydrocortisone, hydromorphone, ifosfamide, imipenem/cilastatin, indomethacin, insulin, irinotecan, isoproterenol, lidocaine, linezolid, lorazepam, magnesium sulfate, mannitol, mechlorethamine, meperidine, methadone, methotrexate, methylprednisolone, metoclopramide, metoprolol, metronidazole, milrinone, mitoxantrone, morphine, multivitamins, nafcillin, naloxone, nesiritide, nitroglycerin, nitroprusside, norepinephrine, octreotide, ondansetron, oxacillin, oxaliplatin, oxytocin, paclitaxel, palonosetron, pamidronate, pemetrexed, penicillin G, phenobarbital, phenylephrine, phytonadione, piperacillin/tazobactam, potassium acetate, potassium chloride, procainamide, propranolol, ranitidine, remifentanil, sodium acetate, sodium bicarbonate, streptokinase, succinylcholine, sufentanil, tacrolimus, teniposide, theophylline, thiotepa, ticarcillin/clavulanate, tigecycline, tirofiban, tobramycin, trimetaphan, vasopressin, verapamil, vincristine, voriconazole, zoledronic acid
  • Y-Site Incompatibility: acyclovir, amphotericin B colloidal, azathioprine, azithromycin, calcium chloride, caspofungin, chlorpromazine, dantrolene, diazepam, diazoxide, diltiazem, diphenhydramine, dobutamine, doxycycline, epirubicin, erythromycin, esmolol, fenoldopam, ganciclovir, gemcitabine, haloperidol, hydroxyzine, idarubicin, labetalol, levofloxacin, methoxamine, midazolam, mycophenolate, nalbuphine, pantoprazole, papaverine, pentamidine, pentazocine, phentolamine, phenytoin, prochlorperazine, promethazine, protamine, pyridoxime, quinupristin/dalfopristin, rocuronium, tolazoline, trimethoprim/sulfamethoxazole, vancomycin, vecuronium, vinorelbine
  • Solution Compatibility: D5/0.9% NaCl, D5W, Ringer’s injection, lactated Ringer’s injection, 0.9% NaCl
  • Intranasal: Activate pump before first use by holding bottle arm’s length away with index finger and middle finger resting on top of finger flange and thumb supporting base. Press down evenly and release pump 5 times to activate. Prior to each use, blow nose gently to clear nostrils. Sit up straight or stand. Tilt head slightly forward. Insert tip of container into nostril. Point container away from center of nose. Push down to spray. Bottles are for 24 hr use; discard bottle no more than 24 hours after taking first dose, even if the bottle still contains some liquid.

Patient/Family Teaching

  • Instruct patient on how and when to ask for and take pain medication.
  • Instruct patient to take medication exactly as directed. Take missed doses as soon as remembered if not almost time for next dose. Do not double doses. Do not take more than prescribed or for longer than 5 days.
    • May cause drowsiness or dizziness. Advise patient to avoid driving or other activities requiring alertness until response to the medication is known.
    • Caution patient to avoid the concurrent use of alcohol, aspirin, NSAIDs, acetaminophen, or other OTC medications without consulting health care professional.
    • Advise patient to inform health care professional of medication regimen prior to treatment or surgery.
    • Advise patient to consult health care professional if rash, itching, visual disturbances, tinnitus, weight gain, edema, black stools, persistent headache, or influenza-like syndrome (chills, fever, muscle aches, pain) occurs.
  • Intranasal: Instruct patient on correct technique for administration, need to open a new bottle every 24 hr, and the 5 day limit for use.

Evaluation/Desired Outcomes

  • Decrease in severity of pain. Patients who do not respond to one NSAID may respond to another.

Toradol

A brand name for KETOROLAC.
References in periodicals archive ?
The pain medications included "opioids, Toradol, and other non-steroidal antiinflammatory medications, local anesthetics, and combinations thereof--all in an effort to return players to the game, rather than allow them to rest and heal properly from serious, football-related injuries.
Toradol, which can be injected, was described as ''the current game-day drug of choice of the NFL.
During his recovery, he allegedly suffered nerve damage when he received an injection of the pain medication Toradol in the front of his right thigh.
The doctor phoned a prescription for the drug Toradol to the patient's long-term pharmacy, which was familiar with her other medications and the fact that she was allergic to nonsteroidal anti-inflammatory drugs like Toradol.
Rafael Castillo, medical columnist of the Inquirer, writes that the painkiller Toradol, a shot of which the Nevada State Athletic Commission refused Pacquiao, would have given the fighter a false sense of assurance that he was injury-free.
Brand names of drugs mentioned in this article Drug Brand name NSAIDs Diclofenac sodium Voltaren (and others) Ketorolac tromethamine Toradol (and others) Mefenamic acid Ponstel (and others) Naproxen sodium Naprelan (and others) Triptans Eletriptan hydrobromide Relpax Frovatriptan succinate Frova Naratriptan hydrochloride Amerge Sumatriptan succinate Imitrex Ergotamines Dihydroergotamine mesylate D.
A gastrointestinal (GI) cocktail of Nitropaste and Toradol didn't relieve the pain, nor did Ativan.
Just to make sure, however, they sought the permission of the Nevada State Athletic Commission (NSAC) to inject Toradol, an anti-inflammatory drug, three hours prior to the 12-round bout.
His experience in product launch is evidenced by products such as TORADOL, TICLID, Synerel and Cytovene.
Toradol is a prostaglandin synthetase inhibitor and has a peripheral effect as well.
The firm shows promise in Cardene (a calcium-channel blocker), Cytovene for treating an eye disease tied to AIDS, Toradol (an analgesic) and Synarel for endometriosis.