Ketorolac DT

Ketorolac DT is a potent non‑steroidal anti‑inflammatory drug (NSAID) marketed in a 10 mg tablet. It provides opioid‑level analgesia for short‑term, moderate‑to‑severe dental pain (e.g., post‑extraction, third‑molar surgery, acute pulpitis). Because of its strength, it carries serious safety warnings that must be respected in everyday practice.

Dosing & Administration

Patient	Dose	Frequency	Maximum Duration
Adults (≥18 y)	10 mg oral tablet	Every 6 hours as needed	≤ 5 days total (including any IV/IM ketorolac)
Elderly (>65 y)	10 mg oral tablet	Every 8 hours as needed	≤ 5 days (use the lowest effective dose)
Renal impairment – avoid if creatinine clearance < 30 mL/min.
Pediatrics – Not indicated for patients < 18 y.

Boxed Warning (the most serious safety alert)

• Gastrointestinal (GI) risk – Ketorolac can cause peptic ulcers, GI bleeding, or perforation, which may be fatal. These events can occur at any time, even without prior symptoms.
• Duration limit – Total combined use of oral and injectable ketorolac must not exceed 5 days.
• Elderly patients are at higher risk for serious GI complications.

Key Safety Considerations

• GI tract – Avoid in patients with active peptic ulcer disease, recent GI bleed, or a history of ulceration.
• Cardiovascular – Contraindicated for peri‑operative pain in coronary artery bypass graft (CABG) surgery; use caution in patients with uncontrolled hypertension or heart failure.
• Renal – Not for patients with severe renal impairment; NSAIDs can reduce renal perfusion.
• Pregnancy – Avoid in the third trimester (risk of premature closure of the ductus arteriosus).
• Bleeding risk – Use with caution in patients on anticoagulants, antiplatelet agents, or with coagulation disorders.

Common Drug Interactions to Watch

• Anticoagulants/antiplatelets (warfarin, clopidogrel, aspirin) – ↑ bleeding risk.
• Other NSAIDs or COX‑2 inhibitors – Additive GI and renal toxicity.
• ACE inhibitors/ARBs & diuretics – May precipitate acute renal failure, especially in volume‑depleted patients.
• Lithium – NSAIDs can raise lithium levels → toxicity.
• Methotrexate – Reduced clearance → toxicity.

Practical Dental Tips

• Pre‑operative assessment – Review the patient’s medication list for NSAID, anticoagulant, or renal‑risk drugs before prescribing ketorolac.
• Post‑operative instructions – Advise patients to take the tablet with food or milk to lessen GI irritation, and to stop use immediately if they notice black stools, vomiting blood, or severe abdominal pain.
• Alternative analgesics – For patients with contraindications, consider acetaminophen + low‑dose ibuprofen (if renal function permits) or short‑course opioids with strict monitoring.
• Documentation – Record the indication, dose, start/stop dates, and any patient‑specific risk factors in the chart.

Quick Reference

• Indication: Moderate‑to‑severe acute dental pain, opioid‑level analgesia.
• Dose: 10 mg PO q6h (adults), max 5 days total.
• Boxed warning: Fatal GI ulceration/bleeding/perforation; limit to 5 days.
• Contraindications: Active peptic ulcer, recent GI bleed, severe renal impairment, pediatric < 18 y, CABG peri‑op pain, third‑trimester pregnancy.
• Key interactions: Anticoagulants, other NSAIDs, ACE‑I/ARBs, lithium, methotrexate.

Clinical Pearls

Start low, go slow – Even though the standard dose is 10 mg, consider extending the interval to q8h in elderly or high‑risk patients.

Combine with gastro‑protection – A proton‑pump inhibitor (e.g., omeprazole) can mitigate GI risk for patients with a prior ulcer history.

Check renal labs – A quick serum creatinine before prescribing can prevent inadvertent renal injury.

Educate patients – Emphasize that ketorolac is not for chronic pain; prolonged use dramatically raises GI and cardiovascular danger.

Document the “5‑day rule” – Write the stop date on the prescription to avoid accidental overuse.