Ketorolac vs. ibuprofen (Advil)

• Ketorolac and ibuprofen (Advil) are nonsteroidal anti-inflammatory drugs (NSAIDs) used to treat varying levels of pain.
• Ketorolac is used for short-term management (up to 5 days) of moderately severe acute pain that otherwise would require narcotics.
• Ibuprofen is used to treat mild to moderate pain, inflammation and fever caused by many and diverse diseases. It is used for treating menstrual cramps (dysmenorrhea), osteoarthritis, rheumatoid arthritis, and juvenile idiopathic arthritis.
• Brand names for ketorolac include Acuvail, Acular LS, Omidria, and Sprix. The Toradol brand of ketorolac has been discontinued in the U.S.
• Ibuprofen is available over-the-counter (OTC) and as a generic. Brand names for ibuprofen include Advil and Motrin.
• Side effects of ketorolac and ibuprofen that are similar include rash, ringing in the ears, headaches, dizziness, drowsiness, abdominal pain, nausea, diarrhea, constipation, and heartburn.
• Side effects of ketorolac that are different from ibuprofen include indigestion, itching, and fluid retention.

Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) used for short-term management (up to 5 days) of moderately severe acute pain that might otherwise require narcotics. Ketorolac is not used for minor or chronic painful conditions. Other NSAIDs include ibuprofen (Advil, Motrin) and naproxen (Naprosyn, Aleve), but ketorolac is more effective than other NSAIDs in reducing pain. Ketorolac blocks the enzymes cells use to make prostaglandins (cyclooxygenase 1 and 2). As a result, pain and inflammation, and signs and symptoms of redness, swelling, fever, and pain, are reduced.

Ibuprofen (Advil, Motrin) is a nonsteroidal anti-inflammatory drug (NSAID) used to treat mild to moderate pain, inflammation, and fever caused by many and diverse diseases. It is used for treating menstrual cramps (dysmenorrhea), osteoarthritis, rheumatoid arthritis, and juvenile idiopathic arthritis. Intravenous ibuprofen is used for treating patent ductus arteriosus. Other NSAIDs include aspirin, naproxen (Aleve), indomethacin (Indocin), and nabumetone (Relafen). Pain, fever, and inflammation are promoted by the release in the body of chemicals called prostaglandins. Ibuprofen blocks the enzyme that makes prostaglandins (cyclooxygenase), resulting in lower levels of prostaglandins. As a consequence, inflammation, pain, and fever are reduced.

Ketorolac

Common side effects from ketorolac include:

• Rash
• Ringing in the ears
• Headaches
• Dizziness
• Drowsiness
• Abdominal pain
• Nausea
• Diarrhea
• Constipation
• Indigestion
• Itching
• Heartburn
• Fluid retention

Rare side effects of ketorolac include:

• Abnormal thinking
• Serious allergic reactions
• Blurred vision
• Bronchospasm
• Jaundice
• Depression
• Difficulty concentrating
• Taste abnormality
• Euphoria
• Hemolytic-uremic syndrome
• High potassium blood levels
• Low sodium levels

Serious side effects of ketorolac include:

• Stomach ulcers
• Intestinal bleeding
• Reduced kidney function
• Liver failure

Other serious adverse events include:

• NSAIDs reduce the ability of blood to clot and, therefore, increase bleeding after an injury. Ketorolac may cause ulcers and bleeding in the stomach and intestines, particularly with use for more than five days. Sometimes, stomach ulceration and intestinal bleeding can occur without any abdominal pain. Sometimes, the only signs or symptoms of bleeding may be:
  • Black tarry stools
  • Weakness
  • Dizziness upon standing (orthostatic hypotension)
• NSAIDs reduce the flow of blood to the kidneys and impair function of the kidneys. The impairment is most likely to occur in patients with preexisting impairment of kidney function or congestive heart failure, and use of NSAIDs in these patients should be done cautiously.
• Liver failure has also been associated with ketorolac.
• People who are allergic to aspirin and other NSAIDs should not use ketorolac.
• Individuals with asthma or nasal polyps are more likely to experience allergic reactions to NSAIDs.

Ibuprofen

The most common side effects from ibuprofen are:

• Rash
• Ringing in the ears
• Headaches
• Dizziness
• Drowsiness
• Abdominal pain
• Nausea
• Diarrhea
• Constipation
• Heartburn

NSAIDs reduce the ability of blood to clot and, therefore, increase bleeding after an injury.

Ibuprofen may cause ulceration of the stomach or intestine, and the ulcers may bleed. Sometimes, ulceration can occur without abdominal pain; and due to bleeding, the only signs or symptoms of an ulcer may be black, tarry stools, weakness, and dizziness upon standing (orthostatic hypotension).

Sometimes, ulceration can occur without abdominal pain, due to the bleeding, and the only signs or symptoms of an ulcer are:

• Black, tarry stools
• Weakness
• Dizziness upon standing (orthostatic hypotension)

NSAIDs reduce the flow of blood to the kidneys and impair function of the kidneys. The impairment is most likely to occur in patients who already have impaired function of the kidney or congestive heart failure, and use of NSAIDs in these patients should be cautious.

People who are allergic to other NSAIDs, including aspirin, should not use ibuprofen.

Individuals with asthma are more likely to experience allergic reactions to ibuprofen and other NSAIDs.

Other serious side effects associated with NSAIDs are:

• Fluid retention (edema)
• Blood clots
• Heart attacks
• Hypertension (high blood pressure)
• Heart failure

NSAIDs (except low-dose aspirin) may increase the risk of potentially fatal heart attacks, stroke, and related conditions in people with or without heart disease or risk factors for heart disease. The increased risk of heart attack or stroke may occur as early as the first week of use, and the risk may increase with longer use and is higher in patients who have underlying risk factors for heart and blood vessel disease. Therefore, NSAIDs should not be used for the treatment of pain resulting from coronary artery bypass graft (CABG) surgery.

Ketorolac

• Treatment should begin with ketorolac injection.
• Tablets are used only if treatment is continued after patients begin to eat and drink.
• The total duration of therapy should not exceed 5 days because of the potential for gastrointestinal bleeding and other side effects.
• The recommended adult intravenous single dose is 15 to 60 mg.
• Multiple intravenous doses of 15 or 30 mg every 6 hours, not to exceed 60 or 120 mg a day, also may be used.
• Following intravenous therapy, the recommended dose is 1 (10 mg) or 2 (20 mg) tablets initially followed by 1 (10 mg) tablet every 4 to 6 hours, not to exceed 40 mg daily.
• The smaller dose is used for patients with poor kidney function or those older than 65 years.
• Oral ketorolac is not approved for individuals less than 17 years of age.

Ibuprofen

• For minor aches, mild to moderate pain, menstrual cramps, and fever, the usual adult dose is 200 or 400 mg every 4 to 6 hours.
• Arthritis is treated with 300 to 800 mg 3 or 4 times daily.
• When under the care of a physician, the maximum dose of ibuprofen is 3.2 g daily. Otherwise, the maximum dose is 1.2 g daily.
• Individuals should not use ibuprofen for more than 10 days for the treatment of pain or more than 3 days for the treatment of a fever unless directed by a physician.
• Children 6 months to 12 years of age usually are given 5 to 10 mg/kg of ibuprofen every 6 to 8 hours for the treatment of fever and pain. The maximum dose is 40 mg/kg daily.
• Juvenile arthritis is treated with 20 to 40 mg/kg/day in 3 to 4 divided doses.
• Ibuprofen should be taken with meals to prevent stomach upset.

Ketorolac

• Probenecid (Benemid) should not be combined with ketorolac because it reduces the elimination of ketorolac by the kidneys. This may lead to increased levels of ketorolac in the body and increased side effects from ketorolac.
• Ketorolac may increase the blood levels of lithium (Eskalith, Lithobid) by reducing the elimination of lithium by the kidneys. Increased levels of lithium may lead to lithium toxicity.
• Concomitant use of ketorolac and angiotensin converting enzyme (ACE) inhibitors may reduce the function of the kidneys.
• Individuals taking oral blood thinners or anticoagulants for example, warfarin (Coumadin, Jantoven), should avoid ketorolac because ketorolac also thins the blood, and excessive blood thinning may lead to bleeding.

Ibuprofen

Ibuprofen is associated with several suspected or probable interactions that can affect the action of other drugs.

• Ibuprofen may increase the blood levels of lithium (Eskalith, Lithobid) by reducing the excretion of lithium by the kidneys. Increased levels of lithium may lead to lithium toxicity.
• Ibuprofen may reduce the blood pressure-lowering effects of drugs that are given to reduce blood pressure. This may occur because prostaglandins play a role in the regulation of blood pressure.
• When ibuprofen is used in combination with methotrexate (Rheumatrex, Trexall) or aminoglycosides (for example, gentamicin), the blood levels of the methotrexate or aminoglycoside may increase, presumably because their elimination from the body is reduced. This may lead to more methotrexate or aminoglycoside-related side effects.
• Ibuprofen increases the negative effect of cyclosporine on kidney function.
• Individuals taking oral blood thinners or anticoagulants -- for example, warfarin (Coumadin) -- should avoid ibuprofen because ibuprofen also thins the blood, and excessive blood thinning may lead to bleeding.
• If aspirin is taken with ibuprofen, there may be an increased risk for developing an ulcer.
• Persons who have more than three alcoholic beverages per day may be at increased risk of developing stomach ulcers when taking ibuprofen or other NSAIDs.
• Combining SSRIs or selective serotonin reuptake inhibitors -- for example, fluoxetine (Prozac), citalopram (Celexa), paroxetine (Paxil, Paxil CR, Pexeva) -- with NSAIDs may increase the likelihood of upper gastrointestinal bleeding.

Ketorolac

There are no adequate studies in pregnant women. Ketorolac should only be used during pregnancy if the potential benefit justifies the potential risk to the fetus. NSAIDs may cause cardiovascular side effects during late pregnancy.

Ketorolac should not be used by nursing mothers because it is excreted in breast milk.

Ibuprofen

There are no adequate studies of ibuprofen in pregnant women. Therefore, ibuprofen is not recommended during pregnancy. Ibuprofen should be avoided in late pregnancy due to the risk of premature closure of the ductus arteriosus in the fetal heart.

Ibuprofen is excreted in breast milk but the American Academy of Pediatrics states that ibuprofen is compatible with breastfeeding.