Ketorolac vs. tramadol

• Ketorolac and tramadol are used to treat moderate to moderately severe pain.
• Brand names for ketorolac include Acuvail, Acular LS, Omidria, and Sprix. The Toradol brand of ketorolac has been discontinued in the U.S.
• Brand names for tramadol include Ultram and ConZip.
• Ketorolac and tramadol belong to different drug classes. Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) and tramadol is a pain reliever (analgesic) that acts similar to narcotics.
• Side effects of ketorolac and tramadol that are similar include headaches, dizziness, nausea, constipation, and indigestion.
• Side effects of ketorolac that are different from tramadol include rash, ringing in the ears, drowsiness, abdominal pain, diarrhea, itching, heartburn, and fluid retention.
• Side effects of tramadol that are different from ketorolac include euphoria, muscle spasm, weakness, drowsiness, and vomiting.

Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) used for short-term management (up to 5 days) of moderately severe acute pain that otherwise would require narcotics. Ketorolac should not be used for minor or chronic painful conditions. Other NSAIDs include ibuprofen (Advil, Motrin) and naproxen (Aleve, Naprosyn), but ketorolac is more effective than other NSAIDs in reducing pain from both inflammatory and non-inflammatory causes. Ketorolac reduces the production of prostaglandins, chemicals that immune system cells make that cause the redness, fever, and pain of inflammation and that also may be important in the production of non-inflammatory pain. Ketorolac blocks the enzymes that 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.

Tramadol is a pain reliever (analgesic) used to manage moderate to moderately severe pain. The exact mechanism of action of tramadol is unknown, but it is similar to morphine. Like morphine, tramadol binds to receptors in the brain (narcotic or opioid receptors) that are important for transmitting the sensation of pain from throughout the body to the brain. Like other narcotic pain relievers, patients taking tramadol may abuse the drug and become addicted to it. Tramadol is not a nonsteroidal anti-inflammatory drug (NSAID) so it does not have the increased risk of stomach ulcers and internal bleeding that can occur with NSAIDs.

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.

Tramadol

Tramadol is generally well tolerated, and side effects are usually temporary.

Commonly reported side effects include

• Nausea
• Constipation
• Dizziness
• Headache
• Euphoria
• Indigestion
• Spasticity
• Weakness
• Drowsiness
• Vomiting

Less commonly reported side effects include

• Itching
• Sweating
• Dry mouth
• Diarrhea
• Rash
• Visual disturbances
• Vertigo

Some patients who received tramadol have reported seizures. It may cause serotonin syndrome when combined with other drugs that also increase serotonin (see drug interactions section).

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.

Tramadol

• The recommended dose of tramadol is 50 to 100 mg (immediate release tablets) every 4 to 6 hours as needed for pain.
• The maximum dose is 400 mg/day.
• To improve tolerance patients should be started at 25 mg/day, and doses may be increased by 25 to 50 mg every 3 days to reach 50 to 100 mg/day every 4 to 6 hours.
• The recommended dose for extended release tablets is 100 mg daily, which may be increased by 100 mg every 5 days, but not to exceed 300 mg/day. To convert from immediate release to extended release, the total daily dose should be rounded down to the nearest 100 mg. Extended release tablets should be swallowed whole and not crushed or chewed.
• Tramadol may be taken with or without food.

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.

Tramadol

• Carbamazepine (Tegretol, Tegretol XR, Equetro, Carbatrol) reduces the effect of tramadol by increasing its inactivation in the body.
• Quinidine (Quinaglute, Quinidex) reduces the inactivation of tramadol, thereby increasing the concentration of tramadol by 50% to 60%.
• Combining tramadol with monoamine oxidase inhibitors or MAOIs -- for example, tranylcypromine (Parnate) -- or selective serotonin reuptake inhibitors (SSRIs) -- for example, fluoxetine (Prozac) -- may result in severe side effects such as seizures or a condition called serotonin syndrome.
• Tramadol may increase central nervous system and respiratory depression when combined with alcohol, anesthetics, narcotics, tranquilizers, or sedative hypnotics. This can reduce the level of consciousness or lead to respiratory insufficiency.

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.

Tramadol

Researchers have not established the safety of tramadol during pregnancy.

Mothers who are breastfeeding should not take tramadol because the infant may develop side effects, and will develop symptoms of withdrawal and difficulty breathing.