Ketorolac, commonly known by the brand name Toradol, is a powerful nonsteroidal anti-inflammatory drug (NSAID) prescribed for the short-term management of moderate to severe pain. While effective, it carries a significant risk of severe side effects, especially when combined with other drugs. For patient safety, it is imperative to understand what meds cannot be taken with ketorolac.
Contraindicated and Highly Risky Drug Combinations
Certain drug combinations with ketorolac can lead to life-threatening complications and are strictly contraindicated. These typically involve drugs that amplify ketorolac’s primary risks, such as bleeding and kidney damage.
Other Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) and Aspirin
Combining ketorolac with other NSAIDs, such as ibuprofen (Advil, Motrin), naproxen (Aleve), and meloxicam, is strictly prohibited. This is due to a synergistic effect that significantly increases the risk of severe gastrointestinal (GI) toxicity, including bleeding, ulceration, and perforation. Similarly, taking ketorolac with aspirin, a blood-thinning NSAID, is not recommended due to the potential for increased adverse effects.
Blood Thinners (Anticoagulants and Antiplatelets)
Ketorolac inhibits platelet function, which is a key component of blood clotting. When taken with other medications that thin the blood, the risk of severe bleeding and hemorrhage increases dramatically. This includes prescription anticoagulants and antiplatelet drugs.
- Anticoagulants: Medications like warfarin (Coumadin), heparin, apixaban (Eliquis), dabigatran (Pradaxa), and rivaroxaban (Xarelto) are particularly dangerous when combined with ketorolac. The combination has a synergistic effect, meaning the bleeding risk is higher than taking either drug alone.
- Antiplatelets: Drugs such as clopidogrel (Plavix) and ticagrelor (Brilinta) also prevent blood clots. Combining them with ketorolac can lead to a dangerously high risk of internal bleeding.
Probenecid
Probenecid, a medication used to treat gout, should never be taken with ketorolac. It significantly decreases the clearance of ketorolac from the body, causing a dangerous buildup of the drug in the bloodstream. This can lead to a heightened risk of ketorolac's adverse effects.
Pentoxifylline
Pentoxifylline, used to treat certain blood flow problems, is another medication strictly contraindicated with ketorolac due to an increased risk of bleeding.
Medications Requiring Extreme Caution and Monitoring
Some drug combinations may not be strictly contraindicated but require close medical supervision. The risks can be significant, and your doctor may need to adjust dosages or monitor you closely.
Methotrexate
This immunosuppressant and chemotherapy agent can have its toxicity dangerously enhanced by ketorolac. Ketorolac interferes with the kidney's ability to clear methotrexate, which can lead to severe side effects such as bone marrow suppression, liver, and kidney toxicity. The risk is particularly high with high-dose methotrexate regimens.
Diuretics
Known as "water pills," diuretics like furosemide (Lasix) and thiazides are used to treat high blood pressure and fluid retention. Ketorolac can inhibit the effects of diuretics and also increase the risk of kidney dysfunction, especially in volume-depleted patients. Patients on this combination should be monitored for signs of renal failure.
Angiotensin-Converting Enzyme (ACE) Inhibitors and Angiotensin II Receptor Blockers (ARBs)
These common blood pressure medications, including lisinopril and losartan, can increase the risk of kidney problems when combined with ketorolac, particularly in patients with pre-existing kidney issues.
Lithium
Ketorolac can cause a significant elevation in plasma lithium levels and reduce its renal clearance. This increases the risk of lithium toxicity, which can have serious neurological and cardiac side effects. Close monitoring of lithium levels is essential.
Cyclosporine
Cyclosporine, an immunosuppressant used in transplant patients, poses a higher risk of kidney toxicity when combined with ketorolac. The combination can worsen kidney function and requires careful monitoring.
Comparison of Key Drug Interactions
To help visualize the severity of interactions, the following table compares the risks of combining ketorolac with different drug types.
| Drug Class or Medication | Interaction Risk | Mechanism of Action | Recommended Action |
|---|---|---|---|
| Other NSAIDs/Aspirin | Major: High risk of GI bleeding, ulceration, and renal failure. | Synergistic GI and renal toxicity. | Contraindicated. Avoid completely. |
| Anticoagulants (e.g., Warfarin) | Major: Severe bleeding and hemorrhage. | Inhibits platelet function, amplifies anticoagulant effects. | Contraindicated. Monitor closely if unavoidable. |
| Probenecid | Major: Ketorolac toxicity due to drug buildup. | Blocks ketorolac clearance from the body. | Contraindicated. Avoid completely. |
| Methotrexate | Major/Moderate: Increased methotrexate toxicity. | Decreases renal clearance of methotrexate. | Use with extreme caution. Requires close monitoring of blood counts and kidney function. |
| Diuretics | Moderate: Reduced diuretic effect; risk of kidney damage. | Inhibits renal prostaglandin synthesis; can cause fluid retention. | Requires monitoring of blood pressure and kidney function. |
| ACE Inhibitors/ARBs | Moderate: Increased risk of kidney impairment. | Affects renal function, especially in dehydrated patients. | Requires close monitoring of blood pressure and kidney function. |
| Lithium | Moderate: Increased lithium toxicity. | Reduces renal clearance of lithium, increasing its blood levels. | Requires frequent monitoring of lithium levels. |
Alcohol and Ketorolac
Alcohol is also a significant concern, as it can heighten the risk of gastrointestinal bleeding when combined with ketorolac. Both substances irritate the stomach lining, and the combined effect can increase the likelihood of ulcers and bleeding. It is best to avoid alcohol entirely while on ketorolac treatment.
Conclusion: Prioritize Communication with Your Doctor
The list of medications and substances that can interact with ketorolac is extensive and can have serious, even fatal, consequences. The short-term nature of ketorolac therapy (typically no longer than five days) is designed to minimize these risks, but interactions can occur quickly. Always provide your healthcare provider and pharmacist with a complete list of all medications, including over-the-counter products, supplements, and herbal remedies, before starting ketorolac. Never start, stop, or change any medication while taking ketorolac without consulting a medical professional. Your proactive communication is the best defense against dangerous drug interactions.
For more detailed information on specific drug interactions, refer to resources like the Drugs.com Interaction Checker.
