Consumer medicine information

TORADOL® Injection

Ketorolac trometamol

BRAND INFORMATION

Brand name

Toradol Solution for injection

Active ingredient

Ketorolac trometamol

Schedule

S4

 

Consumer medicine information (CMI) leaflet

Please read this leaflet carefully before you start using TORADOL® Injection.

What is in this leaflet

This leaflet answers some common questions about TORADOL injection. It does not contain all the available information.

It does not take the place of talking to your doctor or pharmacist.

All medicines have risks and benefits. Your doctor has weighed the risks of you using TORADOL injection against the benefits they expect it will have for you.

If you have any concerns about being given this medicine, ask your doctor or pharmacist.

Keep this leaflet with the medicine.

You may need to read it again.

What TORADOL is given for

TORADOL belongs to a family of medicines called Non-Steroidal Anti-Inflammatory Drugs (NSAIDs).

TORADOL relieves pain and reduces inflammation (swelling and soreness) that may occur following surgery. Although TORADOL can relieve the symptoms of pain and inflammation, it will not cure your condition.

Your doctor may have prescribed TORADOL for another purpose.

Ask your doctor if you have any questions why TORADOL has been prescribed for you.

This medicine is available only with a doctor's prescription.

TORADOL is not addictive.

Before you are given TORADOL

When you must not use it

Do not use TORADOL if:

  1. you have an allergy to:
    - TORADOL or any ingredients listed at the end of this leaflet
    - aspirin or any other NSAID medicine

    Many medicines used to treat headache, period pain and other aches and pains contain aspirin or NSAID medicines. If you are not sure if you are taking any of these medicines, ask your doctor or pharmacist.
    Symptoms of an allergic reaction to these medicines may include:
    - asthma, wheezing or shortness of breath
    - swelling of the face, lips or tongue which may cause difficulty in swallowing or breathing
    - hives, itching or skin rash
    - fainting
    If you are allergic to aspirin or NSAID medicines and use TORADOL, these symptoms may be severe.
  2. you are pregnant, or intend to become pregnant
    TORADOL may affect your developing baby if you use it during pregnancy.
  3. you are breast-feeding or intend to breast-feed
    TORADOL passes into breast milk. The effect on the baby is not known.
  4. you have kidney disease
  5. you have severe liver disease
  6. you have severe heart failure
  7. you have recently had or are about to have heart bypass surgery
  8. you have a peptic ulcer (stomach or duodenal ulcer), a recent history of one, or have had peptic ulcers before
  9. you have had any bleeding disorders
  10. you have asthma
  11. you suffer dehydration
  12. you have nasal polyps syndrome, angioedema or bronchospasm (breathing difficulties)
  13. you have a history of Stevens-Johnsons Syndrome (a rare skin condition with severe blisters and bleeding in the lips, eyes, mouth, nose and genitals).
  14. you are receiving the following medicines:
    - other NSAID medicines
    - probenecid, a medicine used to treat gout
    - lithium, a medicine used to treat some types of depression
    - oxpentifylline, a medicine used to treat certain blood disorders
  15. the packaging is torn or shows signs of tampering.
  16. the expiry date (EXP) printed on the pack has passed.
    If you use this medicine after the expiry date has passed, it may not work as well.

Do not give TORADOL to a child under 16 years of age.

The safety and effectiveness in children under 16 have not been established.

If you are not sure if you should be given TORADOL, contact your doctor.

Before you are given it

Tell your doctor if:

  1. you have any allergies to:
    - any other medicines
    - any other substances, such as foods, preservatives or dyes
  2. you intend to become pregnant
    TORADOL may impair fertility and is not recommended in women attempting to conceive.
    If it is necessary for you to be given TORADOL, your doctor will discuss the risks and benefits of receiving it during pregnancy.
  3. you have or have had any medical conditions, especially the following:
    - heartburn, indigestion, stomach ulcers or other stomach problems
    - kidney or liver disease
    - heart failure
    - high blood pressure or heart problems
    - swelling of the ankles or feet
    - inflammatory bowel disease, such as Crohn's disease.
  4. you currently have an infection
    TORADOL may hide some of the signs of an infection (eg pain, fever) and may make you think that the infection is not serious or that you are better.
  5. you plan to have surgery
  6. you have ever smoked or been a heavy alcohol drinker

If you have not told your doctor about any of the above, tell them before you are given TORADOL.

Taking other medicines

Tell your doctor if you are taking any other medicines including any that you buy without a prescription from your pharmacy, supermarket or health food shop.

Some medicines and TORADOL may interfere with each other. These include:

  • aspirin, salicylates or other NSAID medicines (such as ibuprofen or naproxen)
  • warfarin, a medicine used to stop blood clots
  • probenecid, a medicine used to treat gout
  • oxpentifylline, a medicine used to treat certain blood disorders
  • lithium, a medicine used to treat some types of depression
  • selective serotonin reuptake inhibitors (SSRIs), medicines used to treat depression (such as fluoxetine, paroxetine or citalopram)
  • thiothixene, a medicine used to treat psychosis
  • diuretics, also called fluid or water tablets
  • phenytoin, a medicine used to treat epilepsy
  • carbamazepine, a medicine used to treat epilepsy
  • methotrexate, a medicine used to treat arthritis and some cancers
  • heparin, a medicine used to treat blood disorders
  • medicines used to treat high blood pressure, including ACE inhibitors, angiotensin receptor antagonists and beta-blockers.
  • certain antibiotics called aminoglycosides

These medicines may be affected by TORADOL, or may affect how well it works. You may need to use different amounts of your medicine, or you may need to use different medicines. Your doctor will advise you.

Your doctor and pharmacist have more information on medicines to be careful with or avoid while taking TORADOL.

Ask your doctor if you are not sure about this list of medicines.

How TORADOL is given

How much TORADOL is given

TORADOL is given as an injection, into a muscle by a doctor or trained nurse.

The injection should not be injected directly into the veins (intravenously).

Your doctor will decide what dose of TORADOL you will receive. This depends on your condition.

The usual dose for healthy adults is 10 mg to 30 mg every 4 to 6 hours, up to a maximum daily dose of 90 mg.

If you are over 65 years old or have reduced kidney function, your doctor may prescribe a lower dose.

When TORADOL is given

TORADOL injection is given every 4 to 6 hours as required, up to a maximum daily dose of 90 mg.

How long TORADOL is given for

Do not receive TORADOL for longer than 5 days.

Prolonged use may increase the occurrence of side effects.

If you receive too much (overdose)

Immediately telephone your doctor or Poisons Information Centre (telephone 13 11 26) for advice, or go to Accident and Emergency at your nearest hospital, if you think that you or anyone else may have taken too much TORADOL.

Do this even if there are no signs of discomfort or poisoning.

You may need urgent medical attention.

If you receive too much TORADOL, you may have pain or tenderness in the stomach, stomach upset including nausea (feeling sick), vomiting, heartburn, indigestion or cramps.

If you are not sure what to do, contact your doctor or pharmacist.

While you are receiving TORADOL

Things you must do

If you become pregnant while receiving TORADOL, tell your doctor immediately.

Tell all doctors, dentists and pharmacists who are treating you that you have recently been given TORADOL.

If you are going to have surgery tell your doctor you are being given TORADOL.

If you get an infection soon after receiving TORADOL, tell your doctor.

TORADOL may hide some of the signs of an infection and may make you think, mistakenly, that the infection is not serious or that you are better. Signs of an infection may include fever, pain, swelling and redness.

Things to be careful of

Be careful driving or operating machinery until you know how TORADOL affects you.

As with other NSAID medicines, TORADOL may cause dizziness or light-headedness in some people. Make sure you know how you react to TORADOL before you drive a car, operate machinery, or do anything else that could be dangerous if you are dizzy or light-headed. If this occurs do not drive. If you drink alcohol, dizziness or light-headedness may be worse.

Storage

TORADOL will be stored in the pharmacy or on the hospital ward. It is kept in a cool dry place where the temperature stays below 30°C. It should be protected from light.

Side Effects

Tell your doctor or pharmacist as soon as possible if you do not feel well while you are receiving TORADOL.

TORADOL helps most people with pain after surgery but it may have unwanted side effects in a few people. All medicines can have side effects. Sometimes they are serious, most of the time they are not. You may need medical treatment if you get some of the side effects.

Ask your doctor or pharmacist to answer any questions you may have.

Tell your doctor if you notice any of the following and they worry you:

  • stomach upset including nausea (feeling sick), heartburn, indigestion
  • pain in the stomach or wind
  • diarrhoea
  • dizziness
  • drowsiness
  • headache
  • sweating
  • skin rash or hives
  • aching muscles, muscle tenderness or weakness, not caused by exercise
  • pain at site of injection
  • dry mouth
  • feeling extremely thirsty
  • passing more or less urine than normal.

These side effects of TORADOL are usually mild.

Tell your doctor immediately if you notice any of the following:

  • severe pain or tenderness in any part of the stomach or back
  • severe dizziness, spinning sensation
  • severe or persistent headache
  • abnormal vision
  • bleeding or bruising more easily than normal, reddish or purplish blotches under the skin
  • unusual weight gain, swelling of ankles or legs

These are serious side effects. You may need urgent medical attention. Serious side effects are rare.

If any of the following happen, tell your doctor immediately or go to Accident and Emergency at your nearest hospital:

  • vomiting blood or material that looks like coffee grounds
  • bleeding from the back passage (rectum), black sticky bowel motions (stools) or bloody diarrhoea
  • swelling of the face, lips or tongue which may cause difficulty in swallowing or breathing
  • asthma, wheezing, shortness of breath
  • sudden or severe itching, skin rash or hives
  • fainting, seizures or fits
  • pain or tightness in the chest

These are very serious side effects. You may need urgent medical attention or hospitalisation. These side effects are rare.

Other side effects not listed above may also occur in some patients. Tell your doctor if you notice anything else that is making you feel unwell.

Ask your doctor or pharmacist if you do not understand anything in this list.

Do not be alarmed by this list of possible side effects. You may not experience any of them.

Product Description

What TORADOL looks like

TORADOL is a clear to slightly yellow solution in 1 mL glass ampoules.

Ingredients

Active ingredient:

ketorolac trometamol

  • each 10 mg/mL TORADOL injection contains 10 mg of ketorolac trometamol
  • each 30 mg/mL TORADOL injection contains 30 mg of ketorolac trometamol

Inactive ingredients:

  • ethanol
  • sodium chloride
  • sodium hydroxide or hydrochloric acid
  • water for injections

TORADOL does not contain sucrose, gluten, tartrazine or any other azo dyes.

TORADOL comes in packs of 5 ampoules.

TORADOL is also available as a tablet.

Sponsor

Atnahs Pharma Australia Pty Ltd
Level 10
10 Shelley Street,
SYDNEY, NSW, 2000, Australia

Supplier

TORADOL is supplied in Australia by:

Clinect Pty Ltd
120 - 132 Atlantic Drive
Keysborough VIC 3173
Australia

Customer enquiries: 1 800 899 005

Please check with your pharmacist for the latest Consumer Medicine Information.

Australian Registration Number

  • 10 mg/mL: AUST R 34356
  • 30 mg/mL: AUST R 34357

This leaflet was prepared in November 2016.

BRAND INFORMATION

Brand name

Toradol Solution for injection

Active ingredient

Ketorolac trometamol

Schedule

S4

 

Name of the medicine

Ketorolac trometamol (synonym ketorolac tromethamine).

Excipients.

Injection.

Ethanol, sodium chloride, water for injections and sodium hydroxide or hydrochloric acid to adjust pH.

Tablets.

Microcrystalline cellulose, lactose, magnesium stearate and the proprietary ingredients Opadry white YS-1-7002 and Opacode black S-1-17823.

Description

Chemical name: (RS)-5-benzoyl- 2,3-dihydro- 1H-pyrrolizine- 1-carboxylic acid, 2-amino-2-(hydroxymethyl)propane- 1,3-diol salt. CAS: 74103-07-4. Toradol (ketorolac trometamol; synonym ketorolac tromethamine) is a non-narcotic analgesic belonging to the nonsteroidal anti-inflammatory drug (NSAID) class of medicines with analgesic, anti-inflammatory and antipyretic properties.
Toradol is a member of the pyrrolo-pyrrole group of NSAIDs. The medicine is structurally and pharmacologically related to tolmetin and indomethacin, however, unlike these pyrrole acetic acid derivatives, ketorolac is a cyclic propionic derivative. Toradol is a racemic mixture of [-] S and [+] R enantiomers, with the S form having analgesic activity. Ketorolac is a white to off white crystalline substance which discolours on exposure to light. It is soluble in water and has a pKa of 3.54.
Toradol is available as 10 mg/mL (1%) and 30 mg/mL (3%) sterile solutions for injection for intramuscular (IM) administration only. The injection solutions are clear and slightly yellow in colour.
Toradol is also available as a 10 mg white to creamy white, round, bi-convex, film-coated tablet imprinted in black ink with "KET 10" on one side.

Pharmacology

Pharmacodynamics.

Ketorolac trometamol inhibits the cyclooxygenase enzyme system and hence synthesis of prostaglandins. It is considered to be a peripherally acting analgesic. It does not have known effects on opiate receptors. It has no intrinsic effects on respiration and does not exacerbate opioid related respiratory depression or sedation. Ketorolac trometamol has no significant CNS effects in animals and possesses no sedative or anxiolytic properties.

Pharmacokinetics.

Absorption.

The IM form of Toradol is rapidly and completely absorbed (100% bioavailable). Steady-state plasma levels are achieved after dosing every 6 hours for one day. A mean peak plasma concentration of 2.2 microgram/mL occurs an average of 50 minutes after a single 30 mg dose.
Orally administered Toradol is rapidly and completely absorbed with a peak plasma concentration of 0.52 to 1.31 microgram/mL occurring 35 minutes after a single 10 mg dose in fasted subjects. A high fat diet decreased the rate but not the extent of absorption, while antacid had no effect upon ketorolac absorption.

Binding and distribution.

More than 99% of ketorolac in plasma is protein bound. Even at high plasma concentrations (10 microgram/mL) only approximately 5% of albumin binding sites will be occupied. Thus the unbound fraction for each enantiomer will be constant over the therapeutic range. A decrease in serum albumin, however, will result in increased free drug concentrations.
Plasma protein binding is independent of concentration. As ketorolac trometamol is a highly potent medicine and present in low concentrations in plasma, it would not be expected to displace other protein bound medicines significantly.
Nearly all the medicine related material circulating in plasma is ketorolac (96%) or the pharmacologically inactive p-hydroxyketorolac.
The mean apparent volume (Vβ) of ketorolac trometamol following complete distribution is approximately 13 L (this parameter was determined from single dose data).
Ketorolac trometamol poorly penetrates the blood brain barrier (levels in the cerebrospinal fluid were found to be 0.002 times or less than those in plasma).
Ketorolac crosses the placenta (mean umbilical/ maternal vein concentration ratio for ketorolac was 0.116 and this ratio increased as the time from injection to sampling increased). Ketorolac has been detected in human milk at low concentrations (see Precautions, Use in pregnancy and Use in lactation).

Metabolism.

Ketorolac trometamol is largely metabolised in the liver. The major metabolic path of ketorolac in humans is glucuronic acid conjugation. p-Hydroxylation is an additional minor pathway.

Elimination.

The primary route of excretion of ketorolac and its metabolites (conjugates and a p-hydroxy metabolite) is in the urine (mean 91.4%) and the remainder (mean 6.1%) is excreted in the faeces.
The terminal plasma half-life of ketorolac is approximately in the range of 5-6 hours. No changes in clearance occur with chronic dosing.

Pharmacokinetics in special populations.

Elderly patients (65 years of age or older).

In the elderly, the mean terminal plasma half-life of ketorolac trometamol increases from 5 to 7 hours compared with young healthy volunteers (based on single dose data) (see Dosage and Administration). There is little difference in the Cmax for the two groups.

Renally impaired patients.

The mean half-life of ketorolac trometamol in renally impaired patients is between 6 and 19 hours, and is dependent on the extent of the impairment (based on single dose data). There is poor correlation between creatinine clearance and total ketorolac trometamol clearance in the elderly and populations with renal impairment (r = 0.5). In patients with renal disease, the AUC increases by approximately 100% compared with healthy volunteers. The volume of distribution increases by up to 100%. The increase in volume of distribution of ketorolac trometamol implies an increase in unbound fraction. The AUC ratio of the ketorolac trometamol enantiomers in healthy subjects and patients remains similar, indicating there is no selective excretion of either enantiomer in patients compared to healthy subjects.

Hepatically impaired patients.

Patients with impaired hepatic function do not have any clinically important changes in ketorolac pharmacokinetics, although there is a statistically significant prolongation of Tmax and terminal phase half-life compared to young healthy volunteers.

Clinical Trials

Intramuscular.

Controlled clinical trials studying acute severe pain following major surgical procedures such as cholecystectomy, gastric bypass, abdominal hysterectomy, open reduction and fixation of fractures, lumbar laminectomy and extraction of multiple impacted third molar teeth, have established the efficacy of Toradol relative to other analgesics.
Given postoperatively, Toradol 30 mg IM has an onset of action and peak analgesic efficacy comparable to morphine 12 mg IM or pethidine 100 mg IM, and is more effective than morphine 6 mg IM or pethidine 50 mg IM.
Toradol 30 mg IM has a longer duration of action than morphine 12 mg IM or pethidine 100 mg IM. Toradol 10 mg IM gives efficacy equal to or greater than morphine 6 mg IM or pethidine 50 mg IM.

Oral.

Comparative controlled clinical trials studying acute pain following extraction of impacted third molars and orthopaedic, abdominal and gynaecological surgery have established the analgesic efficacy of oral ketorolac trometamol. In a series of clinical trials, Toradol tablets 10 mg have been found superior or equal to aspirin 650 mg, paracetamol 600 and 1000 mg, paracetamol 600 mg plus codeine 60 mg, paracetamol 1000 mg plus codeine 60 mg, and ibuprofen 400 mg.

Indications

Toradol is indicated for the short-term management of moderately severe, acute pain following surgical procedures. The total duration of ketorolac use should not exceed five days.
It is recommended that ketorolac parenteral be used in the immediate postoperative period. Patients can then be converted to the oral formulation (dependent on their analgesic needs), as outlined in the Dosage and Administration section (see Conversion from parenteral to oral therapy). The total period of treatment utilising the oral and/or intramuscular route of administration is not to exceed five days.

General.

Toradol is not recommended for use as an obstetrical preoperative medication or for obstetrical analgesia because it has not been adequately studied for use in these circumstances and because of the known effects of drugs that inhibit prostaglandin biosynthesis on uterine contraction and foetal circulation.
There is no satisfactory evidence for the use of Toradol in acute exacerbations of chronic painful inflammatory conditions (e.g. rheumatoid or osteoarthritis).

Contraindications

Toradol is contraindicated in patients with severe heart failure (see Precautions, Heart failure);
undergoing treatment of perioperative pain in setting of coronary artery surgery (CABG);
with dehydration or hypovolaemia from any other cause;
with severe hepatic impairment;
with moderate or severe renal impairment (serum creatinine > 180 micromol/L) or in patients at risk of renal failure due to volume depletion or dehydration (see Precautions, Renal effects);
with active or a history of gastrointestinal bleeding or perforation, related to previous NSAID therapy. Active or history of recurrent peptic ulcer/ haemorrhage (two or more distinct episodes of proven ulceration or bleeding) (see Precautions, Gastrointestinal effects);
with a history of haemorrhagic diatheses, including coagulation disorders (see Precautions, Haematological effects);
who have had surgery with a high risk of haemorrhage or incomplete haemostasis; and those at high risk of bleeding (see Precautions, Haematologic effects);
with suspected or confirmed cerebrovascular (intracranial) bleeding (see Precautions, Haematologic effects);
on anticoagulation therapy (see Interactions with Other Medicines);
receiving aspirin, other NSAIDs, oxpentifylline, probenecid or lithium (see Interactions with Other Medicines);
with hypersensitivity to ketorolac trometamol or other NSAIDs and those patients in whom aspirin or other prostaglandin synthetase inhibitors induce allergic reactions. Severe anaphylactic-like reactions have been observed in such patients. If such symptoms occur during therapy, treatment should be discontinued (see Precautions, Anaphylactic reactions).;
with the complete or partial syndrome of nasal polyps, angioedema or bronchospasm (see Precautions, Anaphylactic reactions);
with a history of asthma (see Precautions, Anaphylactic reactions);
with a prior history of Stevens-Johnson syndrome or vesicular bullous rash (see Precautions, Severe skin effects and Adverse Effects).
Toradol is also contraindicated for neuraxial (epidural or intrathecal) administration due to the alcohol content of the solution for injection.
Prophylactic administration before surgery, due to inhibition of platelet aggregation; and intraoperatively because of the increased risk of bleeding.
Use in pregnancy, labour, delivery or lactation (see Precautions, Use in pregnancy and Use in lactation).
Children under 16 years of age.

Precautions

Effects on fertility.

Toradol may impair fertility and is not recommended in women attempting to conceive.

Use in pregnancy.

(Category C)
Toradol is not recommended for use during pregnancy, labour and delivery (see Contraindications).
NSAIDs inhibit prostaglandin synthesis and, when given during the latter part of pregnancy, may cause closure of the foetal ductus arteriosus, foetal renal impairment, inhibition of platelet aggregation, and delay labour and birth. Continuous treatment with NSAIDs during the last trimester of pregnancy should only be given on sound indications. During the last few days before expected birth, agents with an inhibitory effect on prostaglandin synthesis should be avoided.
Reproduction studies with Toradol have been performed in rabbits and rats at oral doses of 3.6 and 10 mg/kg/day, respectively. The results from these studies did not reveal any significant evidence of harm to the foetus. However, studies in rabbits have shown a small increase in the incidence of major vessel anomalies.
Data from epidemiological studies suggest an increased risk of miscarriage after the use of a prostaglandin synthesis inhibitor in early pregnancy.

Use in lactation.

Toradol is not recommended for treatment of nursing mothers (see Contraindications).
After a single oral administration of 10 mg of Toradol to humans, the maximum milk concentration observed was 7.3 nanogram/mL and the maximum milk to plasma ratio was 0.037. After one day of dosing (qid), the maximum milk concentration was 7.9 nanogram/mL and the maximum milk to plasma ratio was 0.025.

Paediatric use.

The safety and efficacy in children have not been established, therefore, Toradol is not recommended for use in children under 16 years of age (see Contraindications).

Use in the elderly.

Because ketorolac trometamol is cleared somewhat more slowly by the elderly (see Pharmacokinetics) who are also more sensitive to the fluid retaining, gastrointestinal toxicity and renal impairment effects (see Precautions) of this medicine, extra caution and the lowest effective dose should be used when treating the elderly with Toradol (see Dosage and Administration).

Ability to drive and operate machinery.

Some patients may experience drowsiness, dizziness, vertigo, insomnia or depression with the use of Toradol. If patients experience these or other similar undesirable effects, they should exercise caution in carrying out activities that require alertness.

Cardiovascular thrombotic events.

Observational studies have indicated that nonselective NSAIDs may be associated with an increased risk of serious cardiovascular events, including myocardial infarction and stroke, which may increase with dose or duration of use. Patients with cardiovascular disease, history of atherosclerotic cardiovascular disease or cardiovascular risk factors may also be at greater risk. To minimise the potential risk of an adverse cardiovascular event in patients taking an NSAID, especially in those with cardiovascular risk factors, the lowest effective dose should be used for the shortest possible duration (see Dosage and Administration). Although ketorolac has not been shown to increase thrombotic events such as myocardial infarction, there are insufficient data to exclude such a risk for ketorolac.
Physicians and patients should remain alert for such CV events even in the absence of previous CV symptoms. Patients should be informed about signs and/or symptoms of serious CV toxicity and the steps to take if they occur.
There is no consistent evidence that the concurrent use of aspirin mitigates the possible increased risk of serious cardiovascular thrombotic events associated with NSAID use.

Hypertension.

NSAIDs may lead to the onset of new hypertension or worsening of pre-existing hypertension and patients taking antihypertensives with NSAIDs may have an impaired antihypertensive response. Caution is advised when prescribing NSAIDs to patients with hypertension. Blood pressure should be monitored closely during initiation of NSAID treatment and at regular intervals thereafter.

Heart failure.

Fluid retention and oedema have been observed in some patients taking NSAIDs; therefore, caution is advised in patients with fluid retention, cardiac decompensation, heart failure, hypertension or similar conditions.

Gastrointestinal effects.

Toradol can cause gastrointestinal irritation, ulcers, perforation or bleeding, which can be fatal, at any time, with or without warning symptoms or a previous history of serious gastrointestinal events.
Upper gastrointestinal ulcers, gross bleeding or perforation caused by NSAIDs occur in approximately 1% of patients treated for 3-6 months and in about 2-4% of patients treated for one year. These trends continue with longer duration of use, increasing the likelihood of developing a serious gastrointestinal effect at some time during the course of therapy. However, even short-term therapy is not without risk.
The risk of gastrointestinal bleeding, ulceration or perforation increases with dose and duration of treatment; in patients with a history of ulcer, particularly if complicated with haemorrhage or perforation; in the elderly; and in those with a history of smoking or alcoholism. Caution is advised in these patients and treatment should commence on the lowest dose available. Combination therapy with gastroprotective agents (e.g. misoprostol or proton pump inhibitors) should be considered for these patients.
Elderly and debilitated individuals are more susceptible to gastrointestinal complications (see Dosage and Administration, Elderly for dosage reductions in this patient group). Most reports of fatal gastrointestinal effects are in this population.
NSAIDs should be given with care to patients with a history of inflammatory bowel disease (ulcerative colitis; Crohn's disease) as their condition may be exacerbated.
Caution should be advised in patients receiving concomitant medications which could increase the risk of gastrointestinal ulceration or bleeding, such as NSAIDs, oral corticosteroids; anticoagulants such as warfarin; selective serotonin reuptake inhibitors (SSRIs); or antiplatelet agents such as aspirin, as these combinations may increase the risk of serious gastrointestinal adverse effects (see Interactions with Other Medicines). Combination therapy with gastroprotective agents (e.g. misoprostol or proton pump inhibitors) should be considered for these patients.
Prescribers should warn patients about the signs and symptoms of serious gastrointestinal toxicity. Patients administered Toradol should be instructed to advise their physician immediately if they experience any unusual abdominal symptoms (especially gastrointestinal bleeding). Toradol should be discontinued, appropriate treatment instituted and the patient closely monitored.
In a nonrandomised, in-hospital postmarketing surveillance study, increased rates of clinically serious gastrointestinal bleeding were seen in patients 65 years of age and under who received an average daily dose of greater than ketorolac 90 mg administered IM as compared to those patients receiving parenteral opioids.

Renal effects.

As with other NSAIDs that inhibit prostaglandin biosynthesis, elevations of serum urea, nitrogen, potassium and creatinine have been reported in clinical trials with Toradol, and can occur after one dose. Ketorolac trometamol and its metabolites are eliminated primarily by the kidneys which, in patients with reduced creatinine clearance, will result in diminished clearance of the medicine. Patients with moderate to severe impairment of renal function should not receive Toradol (see Dosage and Administration, Mild renal impairment, for dosage reduction in patients with mild renal impairment, i.e. serum creatinine < 180 micromol/L). Toradol should be used with caution in patients with a history of kidney disease. Renal function should be monitored in patients who have had more than a single intramuscular dose of ketorolac, particularly in elderly patients.
As with other NSAIDs that inhibit prostaglandin biosynthesis, the following renal abnormalities may be associated with the use of Toradol: glomerular nephritis, interstitial nephritis, renal papillary necrosis, nephrotic syndrome, acute renal failure and hyperkalaemia. Other renal conditions/ diseases are possible.
Caution should be observed in patients with conditions leading to a reduction in blood volume and/or renal blood flow, where renal prostaglandins have a supportive role in the maintenance of renal perfusion. In these patients, administration of an NSAID may cause a dose dependent reduction in renal prostaglandin formation and may precipitate overt renal failure. Patients at greatest risk of this effect are those who are volume depleted because of blood loss or severe dehydration, patients with impaired renal function, heart failure, liver dysfunction, the elderly and those taking diuretics. Discontinuation of NSAID therapy is typically followed by recovery to the pretreatment state. Inadequate fluid/ blood replacement during surgery, leading to hypovolaemia (see Contraindications), may lead to renal dysfunction which could be exacerbated when Toradol is administered. Therefore, volume depletion should be corrected and close monitoring of serum urea, serum creatinine and urine output is recommended until the patient is normovolaemic. In patients on renal dialysis, ketorolac clearance is reduced to approximately half the normal rate and terminal half-life increases approximately 3-fold.

Haematologic effects.

Toradol inhibits platelet aggregation and may prolong bleeding time. Unlike the prolonged effects from aspirin, the inhibition of platelet function by Toradol resolves within 24 to 48 hours after the medicine is discontinued. Toradol does not affect platelet count, prothrombin time (PT) or partial thromboplastin time (PTT). In controlled clinical studies, the incidence of clinically significant postoperative bleeding was 5/1,170 (0.4%) compared to 1/570 (0.2%) in the control groups receiving opiates.
The use of Toradol in patients who have coagulation disorders should be undertaken very cautiously, and those patients carefully monitored. Patients on anticoagulation therapy (e.g. heparin or warfarin) may be at increased risk of bleeding if given Toradol concurrently (see Contraindications). The concomitant use of ketorolac and prophylactic low dose heparin has not been studied extensively and may also be associated with an increased risk of bleeding. Concomitant administration of dextrans may also increase the risk of postoperative bleeding. Patients receiving other medicines that affect haemostasis should be carefully observed if Toradol is administered (see Interactions with Other Medicines).
In postmarketing experience, postoperative wound haemorrhage has been reported in association with the immediate perioperative use of intramuscular Toradol. Therefore, ketorolac should not be used in patients who have had surgery with a high risk of haemorrhage or incomplete haemostasis. Caution should be used where strict haemostasis is critical, e.g. in cosmetic or day care surgery, resection of the prostate or tonsillectomy. Haematomata, other signs of wound haemorrhage and epistaxis have been reported with the use of Toradol. Physicians should be aware of the pharmacological similarity of ketorolac to other NSAIDs that inhibit cyclooxygenase and the risk of bleeding, particularly in the elderly.

Hepatic effects.

As with other NSAIDs, borderline elevations of one or more liver function tests may occur in up to 15% of patients. These abnormalities may progress, may remain essentially unchanged or may be transient with continued therapy. The ALT (SGPT) test is probably the most sensitive indicator of liver injury. Meaningful (3 times the upper limit of normal) elevations of ALT or AST (SGOT) have been reported in controlled clinical trials (with the oral formulation of ketorolac trometamol) in less than 1% of patients. If clinical signs and symptoms consistent with liver disease develop, or if systemic manifestations occur (e.g. eosinophilia, rash, etc.), Toradol should be discontinued.
Patients with impaired hepatic function from cirrhosis do not have any clinically important changes in Toradol clearance. Studies to assess the pharmacokinetics of Toradol in patients with active hepatitis or cholestasis have not been done. Physicians and patients should remain alert for hepatotoxicity. Patients should be informed about the signs and/or symptoms of hepatotoxicity.
A patient with symptoms and/or signs suggesting liver dysfunction (e.g. nausea, fatigue, lethargy, pruritis, jaundice, abdominal tenderness in the right upper quadrant and flu-like symptoms), or in whom an abnormal liver test has occurred, should be evaluated for evidence of the development of a more severe hepatic effects while on therapy with Toradol.

Severe skin effects.

NSAIDs may very rarely cause serious cutaneous adverse effects such as exfoliative dermatitis, Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), which can be fatal and occur without warning. These serious adverse effects are idiosyncratic and are independent of dose or duration of use. Patients should be advised of the signs and symptoms of serious skin effects and to consult their physician at the first appearance of a skin rash or other sign of hypersensitivity.

Injection site effects.

Toradol injection administered intramuscularly has produced pain at the injection site in 2 to 4% of patients. Ecchymosis, bruising, haematoma and tingling at the injection site have rarely been reported. Adverse local effects may be minimised by applying pressure at the injection site for 15 to 30 seconds after administration. There has been no evidence (e.g. alterations in serum creatine kinase (CK) or creatine phosphokinase (CPK) concentrations) of substantial adverse muscular tissue effects following single or multiple IM injections of Toradol.

Anaphylactic reactions.

Anaphylactic (anaphylactoid) reactions (including, but not limited to, anaphylaxis, bronchospasm, flushing, rash, hypotension, laryngeal oedema and angioedema) may occur in individuals with or without a history of hypersensitivity to aspirin, other NSAIDs or Toradol. These may also occur in individuals with a history of angioedema, bronchospastic reactivity (e.g. asthma) and nasal polyps. Anaphylactoid reactions, like anaphylaxis, may have a fatal outcome. Therefore, Toradol should be used with caution in patients with a history of asthma and in patients with the complete or partial syndrome of nasal polyps, angioedema and bronchospasm.

Special senses.

Adverse ophthalmological effects have been observed with nonsteroidal anti-inflammatory agents; accordingly, patients who develop visual disturbances during treatment with Toradol should have an ophthalmological examination.

Drug abuse and physical dependence.

Toradol is not a narcotic agonist or antagonist. Subjects did not show any subjective symptoms or objective signs of drug withdrawal upon abrupt discontinuation of intramuscular dosing. Toradol did not exhibit activity in classical animal studies which are reasonable predictors of opiate analgesic action (hot plate and tail withdrawal test). In vitro Toradol does not bind to opiate receptors. These studies demonstrate that Toradol does not have central opiate-like activity.

General.

Undesirable effects may be minimised by using the lowest minimum effective dose for the shortest duration necessary to control symptoms (see Dosage and Administration and Precautions).
Toradol is not an anaesthetic agent and possesses no sedative or anxiolytic properties, therefore, it is not recommended as a preoperative or intraoperative medication for the support of anaesthesia when these effects are required. Toradol IM should not be used for spinal or epidural administration. Toradol IM contains ethanol 10% (see Contraindications).
The total duration of ketorolac treatment should not exceed five days.

Interactions

Protein binding.

Toradol is highly bound to human plasma protein (mean 99.2%) and binding is independent of concentration. The in vitro binding of warfarin to plasma proteins is only slightly reduced by Toradol (99.5% control vs. 99.3% binding with Toradol concentrations of 5 to 10 microgram/mL). Toradol does not alter digoxin protein binding.
In vitro studies indicated that at therapeutic concentrations of salicylate (300 microgram/mL), the binding of Toradol was reduced from approximately 99.2% to 97.5%. Therapeutic concentrations of digoxin, warfarin, ibuprofen, naproxen, paracetamol, phenytoin, tolbutamide and piroxicam did not alter Toradol protein binding. Because Toradol is a highly potent medicine and present in low concentrations in plasma, it would not be expected to displace other protein bound medicines significantly.

Enzyme induction/ inhibition.

There is no evidence in animal or human studies that Toradol induces or inhibits the hepatic enzymes capable of metabolising itself or other medicines. Hence, Toradol would not be expected to alter the pharmacokinetics of other medicines due to enzyme induction or inhibition mechanisms.

Warfarin.

The concurrent use of NSAIDs and warfarin has been associated with severe, sometimes fatal, haemorrhage. The exact mechanism of the interaction between NSAIDs and warfarin is unknown, but may involve enhanced bleeding from NSAID induced gastrointestinal ulceration or an additive effect of anticoagulation by warfarin and inhibition of platelet function by NSAIDs. Toradol should be used in combination with warfarin only if absolutely necessary and patients taking this combination of medicines should be closely monitored.

Anticoagulant therapy and other drugs affecting haemostasis.

NSAIDs may enhance the effects of anticoagulants, such as warfarin, low molecular weight heparin and dextrans (see Contraindications and Precautions, Haematologic effects). Unlike the prolonged effects from aspirin, platelet function returns to normal within 24 to 48 hours after Toradol is discontinued.

Aspirin and other NSAIDs.

In patients concurrently receiving aspirin or other NSAIDs, the risk of inducing serious NSAID related adverse effects may be increased (see Contraindications).

Oxpentifylline.

When Toradol is administered concurrently with oxpentifylline, there is an increased tendency to bleeding (see Contraindications).

Probenecid.

Concomitant administration of oral Toradol and probenecid resulted in decreased clearance of ketorolac and significant increases in ketorolac plasma levels (total AUC increased approximately 3-fold from 5.4 to 17.8 microgram.hour/mL) and terminal half-life increased approximately 2-fold from 6.6 to 15.1 hours. Therefore, the concomitant use of Toradol and probenecid is contraindicated.

Lithium.

Inhibition of renal lithium clearance, leading to an increase in plasma lithium concentration, has been reported with some prostaglandin synthesis inhibiting medicines. The effect of Toradol on plasma lithium has not been studied, but cases of increased plasma levels during Toradol therapy have been reported.

Methotrexate.

Concomitant administration of methotrexate and some NSAIDs has been reported to reduce the clearance of methotrexate, enhancing the toxicity of methotrexate. The effect of Toradol on methotrexate clearance has not been studied.

ACE inhibitors.

As with other NSAIDs, ketorolac may increase the risk of renal impairment associated with the use of ACE inhibitors, particularly in patients that are actually or effectively volume depleted.

Combination use of ACE inhibitors or angiotensin receptor antagonists, anti-inflammatory medicines and thiazide diuretics (triple whammy).

The use of an ACE inhibiting medicine (ACE inhibitor or angiotensin receptor antagonist), an anti-inflammatory medicine (NSAID or COX-2 inhibitor) and a thiazide diuretic at the same time (triple whammy) increases the risk of renal impairment. This includes use in fixed combination products containing more than one class of medicine. Combined use of these medications should be accompanied by increased monitoring of serum creatinine, particularly during initiation of the combination. The combination of medicines from these three classes should be used with caution particularly in elderly patients or those with pre-existing renal impairment.

Diuretics.

Toradol reduces the diuretic response to frusemide in normovolaemic healthy subjects by approximately 20%.

Nephrotoxic agents.

The use of medicines with nephrotoxic activity (e.g. aminoglycoside antibiotics) should be avoided when using Toradol.

Selective serotonin reuptake inhibitors.

There is an increased risk of gastrointestinal bleeding when antiplatelet agents and selective serotonin reuptake inhibitors (SSRIs) are combined with NSAIDs.

Antiepileptic medicines.

Sporadic cases of seizures have been reported during concomitant use of Toradol and antiepileptic medicines (phenytoin, carbamazepine).

Psychoactive medicines.

Hallucinations have been reported when Toradol was used in patients taking psychoactive medicines (fluoxetine, thiothixene, alprazolam).

Adverse Effects

Parenteral administration.

Physicians using Toradol injection should be alert for the usual complications of nonsteroidal anti-inflammatory treatment.
The adverse effects listed below were reported to be probably related to Toradol in clinical trials in which patients received up to 20 doses, in five days, of postoperatively administered Toradol 30 mg intramuscularly and in clinical trials in which patients received up to 8 doses, in two days, of postoperatively administered Toradol 30 mg intravenously.

Incidence between 3% and 9%.

Gastrointestinal disorders.

Nausea, dyspepsia, gastrointestinal pain.

Nervous system disorders.

Drowsiness.

Incidence between 1% and 3%.

Gastrointestinal disorders.

Diarrhoea.

General disorders and administration site conditions.

Oedema, injection site pain was reported by 2% of patients in multidose studies (compared with 5% for the morphine control group).

Nervous system disorders.

Dizziness, headache.

Skin and subcutaneous tissue disorders.

Sweating.

Incidence 1% or less.

Ear disorders.

Vertigo.

Eye disorders.

Abnormal vision.

Gastrointestinal disorders.

Constipation, flatulence, gastrointestinal fullness, liver function abnormalities, melaena, peptic ulcer, rectal bleeding, stomatitis, vomiting.

General disorders and administration site conditions.

Asthenia, excessive thirst.

Musculoskeletal and connective tissue disorders.

Myalgia.

Nervous system disorders.

Dry mouth, paraesthesia, stimulation, abnormal taste.

Psychiatric disorders.

Nervousness, abnormal thinking, depression, euphoria, insomnia, inability to concentrate.

Renal and urinary disorders.

Increased urinary frequency, oliguria.

Respiratory, thoracic and mediastinal disorders.

Dyspnoea, asthma.

Skin and subcutaneous tissue disorders.

Pruritus, urticaria, purpura.

Vascular disorders.

Vasodilation, pallor.

Oral administration.

The incidence of adverse effects in approximately 600 patients and subjects receiving short-term oral therapy with the 10 mg tablet (less than two weeks) is listed below.

Incidence between 1 and 2%.

Gastrointestinal disorders.

Nausea, dyspepsia, gastrointestinal pain.

Nervous system disorders.

Dizziness, headache.

Vascular disorders.

Hypertension.

Incidence 1% or less.

Gastrointestinal disorders.

Flatulence, gastritis.

General disorders and administration site conditions.

Asthenia, oedema.

Musculoskeletal and connective tissue disorders.

Myalgia.

Respiratory, thoracic and mediastinal disorders.

Dyspnoea.

Skin and subcutaneous tissue disorders.

Urticaria, rash, pruritus, purpura.

Postmarketing adverse effects.

The following international postmarketing adverse effects, although rare, have been reported spontaneously for patients who have received ketorolac trometamol.

Blood and lymphatic system disorders.

Thrombocytopenia, epistaxis, haematoma, angioedema.

Cardiac disorders.

Bradycardia, palpitations, cardiac failure.

Ear disorders.

Hearing loss, tinnitus, vertigo.

Eye disorders.

Abnormal vision.

Gastrointestinal disorders.

Gastrointestinal haemorrhage, peptic ulceration, gastrointestinal perforation, nausea, vomiting, diarrhoea, flatulence, eructation, constipation, dyspepsia, abdominal pain/ discomfort, melaena, haematemesis, stomatitis, ulcerative stomatitis, oesophagitis, rectal bleeding, pancreatitis, dry mouth, fullness, exacerbation of colitis and Crohn's disease, gastritis.

General disorders and administration site conditions.

Weight gain, injection site reactions, pallor, fever, asthenia, oedema, excessive thirst, chest pain.

Hepatobiliary disorders.

Hepatitis, cholestatic jaundice, liver failure.

Immune system disorders.

Anaphylaxis, anaphylactoid reactions, hypersensitivity reactions such as flushing, rash, hypotension, bronchospasm and laryngeal oedema (see Precautions, Anaphylactic reactions).

Infection.

Infection, aseptic meningitis.

Investigations.

Abnormal liver function tests, increased serum urea, increased creatinine, prolonged bleeding time.

Metabolic and nutrition disorders.

Hyponatraemia, hyperkalaemia, anorexia.

Musculoskeletal and connective tissue disorders.

Myalgia.

Nervous system disorders.

Headache, dizziness, paraesthesia, convulsions, extrapyramidal symptoms, hyperkinesia, taste abnormality, dry mouth, drowsiness.

Psychiatric disorders.

Abnormal dreams, hallucinations, anxiety, psychotic reactions, abnormal thinking, depression, insomnia, nervousness, euphoria, impaired concentration ability.

Renal and urinary disorders.

Acute renal failure, urinary retention, increased urinary frequency, interstitial nephritis, nephrotic syndrome, haemolytic uraemic syndrome, oliguria, flank pain with or without haematuria and/or azotaemia (see Precautions, Renal effects).

Reproductive system and breast disorders.

Female infertility.

Respiratory, thoracic and mediastinal disorders.

Asthma, dyspnoea, pulmonary oedema.

Skin and subcutaneous tissue disorders.

Rash, Stevens-Johnson syndrome (SJS), exfoliative dermatitis, toxic epidermal necrolysis (TEN), maculopapular rash, Lyell's syndrome, pruritus, urticaria, purpura, sweating.

Vascular disorders.

Hypotension, hypertension, flushing, pallor, postoperative wound haemorrhage (rarely requiring blood transfusion).

Dosage and Administration

Toradol dosage should be adjusted according to the severity of the pain and the response of the patient. The lowest effective dose should be used for the shortest possible time in all patient populations.
Opiate analgesics (e.g. morphine and pethidine) may be used concomitantly, and may be required for optimal analgesic effect in the early postoperative period when pain is most severe, or when the anxiolytic effects and/or sedative effects of opiates are desired. Toradol has been administered with morphine in several clinical trials of postoperative pain without evidence of adverse interactions. Toradol does not exacerbate opioid related respiratory depression or sedation. When used in association with IM Toradol, the daily dose of opioid is usually less than that which is normally required.
Hypovolaemia should be corrected prior to administration of Toradol.
The total duration of Toradol administration should not exceed 5 days because adverse effects may increase with prolonged usage.

Intramuscular administration.

The intramuscular injection should be given slowly and deeply into the muscle.

Adults (under 65 years of age).

The usual recommended initial intramuscular dose is 10 mg to 30 mg, followed by 10 mg to 30 mg at 4 to 6 hourly intervals, up to a maximum daily dose of 90 mg.

Elderly (65 years of age and older).

An initial intramuscular dose of 10 mg to 15 mg, followed by 10 mg to 15 mg at 4 to 6 hourly intervals, up to a maximum daily dose of 60 mg.

Mild renal impairment.

If Toradol is used in patients with mildly impaired renal function (serum creatinine values: males between 130 and 180 micromol/L; females between 120 and 180 micromol/L), the lower end of the IM dosage range should be used. The total daily dose should not exceed 60 mg. Toradol is contraindicated in patients with more severe degrees of renal impairment (see Contraindications).

Cardiovascular.

Patients on long-term treatment should be reviewed regularly with regards to efficacy, risk factors and ongoing need for treatment.

Other.

For patients under 50 kg in bodyweight or for patients with less severe pain, the lower end of the intramuscular Toradol dosage range is recommended. The total daily dose should not exceed 60 mg.
Toradol solution for injection is intended for use in one patient on one occasion only. Discard any residue.

Oral administration.

Adults (under 65 years of age).

The usual oral dose of Toradol is 10 mg every 4 to 6 hours, as required. Doses exceeding 40 mg/day are not recommended.

Elderly (65 years of age and older).

The usual oral dose of Toradol in the elderly is 10 mg every 6 to 8 hours. Daily doses of 30 to 40 mg/day should not be exceeded. The use of Toradol tablets is recommended for the shortest possible time.

Conversion from intramuscular to oral therapy.

For patients being converted from intramuscular Toradol to oral Toradol, the total combined daily dose should not exceed 90 mg (60 mg for the elderly, mildly renally impaired patients and patients weighing less than 50 kg) and the oral component should not exceed 40 mg (30 mg to 40 mg for the elderly) on the day the change of formulation is made. Patients should be converted to oral treatment as soon as possible.

Overdosage

Symptoms and signs.

Single overdoses of Toradol have been variously associated with abdominal pain, nausea, vomiting, hyperventilation, peptic ulcers and/or erosive gastritis and renal dysfunction which have resolved after discontinuation of dosing.
Gastrointestinal bleeding may occur. Hypertension, acute renal failure, respiratory depression and coma may occur after the ingestion of NSAIDs but are rare.
Anaphylactoid reactions have been reported with therapeutic ingestion of NSAIDs and may occur following an overdose.

Treatment.

Patients should be managed by symptomatic and supportive care following NSAID overdose. There are no specific antidotes. Dialysis does not significantly clear ketorolac from the blood stream.
Contact the Poisons Information Centre for advice on management of overdosage.

Presentation

Solution for injection (clear, slightly yellow, sterile), 10 mg/mL, 1 mL: 5's; 30 mg/mL, 1 mL: 5's (glass ampoule).
Tablets, 10 mg (white to cream white, round, biconvex, film coated, marked KET 10 in black on one side): 20's.

Storage

Injection.

Store below 30°C. Protect from light. Shelf life: 2 years.

Tablets.

Store below 30°C. Protect from light. Shelf life: 3 years.

Poison Schedule

S4.