Ketorolac is a potent, short acting nonsteroidal antiinflammatory drug (NSAID) that is available in both parenteral and oral forms. Ketorolac is generally given for a few days only, and has not been linked to instances of idiosyncratic drug induced liver disease in the published literature.
Ketorolac tromethamine belongs to the acetic acid class of NSAIDs similar to diclofenac and etodolac. Like other NSAIDs, ketorolac is a potent cyclo-oxygenase (Cox) inhibitor which blocks the formation of prostaglandins that are important in pain and inflammatory pathways. Ketorolac was approved in the United States in 1991 and current indications are limited to the short term management of moderately severe, acute pain. Ketorolac is available in parenteral and oral forms in multiple generic forms and under the brand name Toradol. The recommended dose is 60 mg intramuscularly or 30 mg intravenously initially, followed by 30 mg every 6 hours for up to 5 days. An oral form is available in 10 mg tablets for switching from the parenteral form and is given every 6 to 8 hours, but continuation beyond 5 days is not recommended. Ketorolac is available by prescription only and it is used largely for management of postoperative pain. Common side effects include gastrointestinal upset, nausea, headache and itching.
Prospective studies show that up to 1% of patients taking ketorolac experience at least transient serum aminotransferase elevations. These may resolve even with drug continuation. Marked aminotransferase elevations (>3 fold elevated) occur in <1% of patients. Clinically apparent liver injury with jaundice from ketorolac has not been reported so that the latency, clinical features and prognosis of injury is unknown. Ketorolac is not mentioned as an etiologic agent in large case series on drug induced liver injury or acute liver failure. However, the antiplatelet activity of ketorolac can lead to complications during relief of postoperative pain, and several instances of hepatic rupture and subcapsular hepatic hematomas have been reported with its use.
Likelihood score: E* (unproven but suspected cause of clinically apparent liver injury, largely due to bleeding episodes).
Mechanism of Injury
The mechanism of ketorolac hepatotoxicity, if it exists, is not known. The hepatic hematomas described after its use are probably caused by the antiplatelet activity of ketorolac given in the perioperative period.
Outcome and Management
Only asymptomatic elevations in serum aminotransferase levels have been reported associated with ketorolac therapy. The drug is rarely used outside of hospitals and it is recommended that it be used for no more than 5 days, perhaps accounting for the rarity or absence of hepatic injury.
REPRESENTATIVE TRADE NAMES
Ketorolac – Generic, Toradol®
Nonsteroidal Antiinflammatory Drugs
Product labeling at DailyMed, National Library of Medicine, NIH
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References updated: 25 April 2018
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and bleeding; no discussion of ALT elevations or
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