Drug Profile

Do Not Use: This drug is no more effective than related drugs and causes a higher rate of ulcers.

The following is an excerpt from the black-box warning required on the label for this drug.[1]

Ketorolac belongs to the family of drugs called nonsteroidal anti-inflammatory drugs, shortened to NSAIDs, often used to treat arthritis in older adults. NSAIDs can cause serious harm, even fatalities, from bleeding in the stomach or intestines. Bleeding can occur at any time and without warning, and older people are more likely to experience adverse effects from bleeding. Older adults are also more likely to have reduced liver and kidney function. Some doctors believe people over age 70 should be started with half the usual dose of drugs in this group.[2]

Ketorolac is approved only for short-term use, five days or less, in the treatment of acute pain. This drug is available in both oral and injectable forms.

The label for ketorolac warns about the risks of gastrointestinal bleeding and kidney and liver damage. It also warns against the use of the drug in labor and delivery, in nursing mothers and in patients before or during surgery. The label cautions that very young or older adults should use the lowest possible dose. Ketorolac remains on a well-recognized list of drugs that are inappropriate for use in older adults.[3]

Side effects

The British Medical Journal (BMJ) published a meta-analysis (a study that combines data from many other studies) examining the use of NSAIDS and cardiovascular safety. The authors of the article stated that there is a risk of cardiovascular adverse effects associated with these drugs, and this risk must be considered when treating patients.[4]

Information from another article in the BMJ found that the use of NSAIDs was associated with the occurrence of abnormal heart rhythms called atrial fibrillation or flutter.[5]

Interactions

Studies suggest a possible harmful interaction between NSAIDs and a class of osteoporosis drugs called bisphosphonates. Patients need to be alert to the fact that the combination can result in an increased risk of ulcers and other gastrointestinal side effects. Read more in the July 2010 issue of Worst Pills, Best Pills News.

Combining NSAIDs with anticoagulants (blood thinners for preventing blood clots) increases the risk of serious bleeding complications.[6]

When not to use NSAIDS

In cases with advanced kidney disease, treatment with NSAIDs is not recommended. However, if NSAID therapy must be initiated, close monitoring of the patient’s kidney function is advisable.

NSAIDS are also contraindicated in patients in whom aspirin or other nonsteroidal anti-inflammatory/analgesic drugs induce the syndrome of asthma, rhinitis and nasal polyps. These reactions have the potential to be fatal. Therefore, careful questioning of patients for asthma, nasal polyps, urticaria (hives) and low blood pressure associated with NSAIDs before starting therapy is important. In addition, if such symptoms occur during therapy, treatment should be discontinued.

Better options available

Among the NSAIDs, evidence shows that ibuprofen (ADVIL, MEDIPREN, MOTRIN, NUPRIN) is less toxic than other drugs in this family to the gastrointestinal tract, which is one of the main safety concerns with NSAIDs.[7],[8],[9],[10],[11]

Aspirin (EASPRIN, ECOTRIN, EMPIRIN, GENUINE BAYER ASPIRIN) is just as effective as and less costly than other NSAIDs and is the drug of choice for treating pain, fever, and inflammation in people who do not have ulcers, gastritis (inflammation of the stomach), or an allergy to aspirin. Some rheumatologists prefer aspirin to other NSAIDs for treating rheumatoid arthritis.[12]

Regulatory actions surrounding ketorolac

2005: The Food and Drug Administration (FDA) requested that manufacturers of NSAIDS, both prescription and over-the-counter, revise the drugs’ labels to include the potentially increased risks of cardiovascular events (read the information noted with COX-2 inhibitors) and gastrointestinal bleeding (see “Warnings” box at top of page). The FDA also required a Medication Guide be provided to patients with each dispensed prescription.

2015: The FDA announced that the agency is strengthening the existing warning for all non-aspirin NSAIDs concerning an increased risk of heart attack and stroke.[13]