Toradol

Ketorolac Trometamol 10mg.

White to creamy white film coated, round tablet, marked “KET 10” on one face, the other face blank.

Toradol tablets are indicated for the short-term management of moderate postoperative pain. Treatment should only be initiated in hospitals. The maximum duration of treatment is seven days.

For oral administration.

To be taken preferably with or after food.

Toradol tablets are recommended for short-term use only (up to 7 days) and are not recommended for chronic use.

Undesirable effects may be minimised by using the lowest effective dose for the shortest duration necessary to control symptoms (see section 4.4).

Adults

10mg every 4 to 6 hours as required. Doses exceeding 40mg per day are not recommended.

Opioid analgesics (e.g. morphine, pethidine) may be used concomitantly, and may be required for optimal analgesic effect in the early postoperative period when pain is most severe. Ketorolac does not interfere with opioid binding and does not exacerbate opioid-related respiratory depression or sedation.

For patients receiving parenteral Toradol, and who are converted to Toradol oral tablets, the total combined daily dose should not exceed 90mg (60mg for the elderly, renally-impaired patients and patients less than 50kg) and the oral component should not exceed 40mg on the day the change of formulation is made. Patients should be converted to oral treatment as soon as possible.

Elderly

The elderly are at increased risk of the serious consequences of adverse reactions. If an NSAID is considered necessary, the lowest effective dose should be used and for the shortest possible duration. The patient should be monitored regularly for GI bleeding during NSAID therapy.

A longer dosing interval, e.g. 6 - 8 hourly, is advisable in the elderly.

Children

Toradol is not recommended for use in children under 16 years of age.

Ketorolac is contraindicated in patients with previously demonstrated hypersensitivity to Ketorolac, any of its excipients, or other NSAIDs and patients in whom aspirin or other prostaglandin synthesis inhibitors induce allergic reactions (severe anaphylactic-like reactions have been observed in such patients). Such reactions have included asthma, rhinitis, angioedema, or urticaria.

Ketorolac is also contraindicated in

- those with a history of asthma

- children under 16 years of age.

Ketorolac is contraindicated in patients with active or a history of gastrointestinal bleeding or perforation, related to previous NSAIDs therapy. Active or history of recurrent peptic ulcer/haemorrhage (two or more distinct episodes of proven ulceration or bleeding).

As with other NSAIDs, Ketorolac is contraindicated in patients with severe heart failure, hepatic failure and renal failure (see section 4.4).

Ketorolac is contraindicated in patients with moderate or severe renal impairment (serum creatinine >160 µmol/l) or in patients at risk for renal failure due to volume depletion or dehydration.

Ketorolac is contraindicated in pregnancy, labour, delivery and lactation (see section 4.6).

Ketorolac is contra-indicated as prophylatic analgesia before surgery due to inhibition of platelet aggregation and is contra-indicated intraoperatively because of the increased risk of bleeding.

Ketorolac inhibits platelet function and is, therefore, contraindicated in patients with suspected or confirmed cerebrovascular bleeding, patients who have had operations with a high risk of haemorrhage or incomplete haemostasis and those at high risk of bleeding such as those with with haemorrhagic diatheses, including coagulation disorders.

It is also contraindicated in patients on anticoagulants, including warfarin and low dose heparin (2500 - 5000 units 12 hourly).

Ketorolac is contraindicated in patients currently receiving ASA or other NSAIDs (including cyclooxygenase-2 selective inhibitors).

The combination of Ketorolac with oxpentifylline is contraindicated.

Concurrent treatment with ketorolac and probenecid or lithium salts is contraindicated.

Ketorolac is contra-indicated in patients with the complete or partial syndrome of nasal polyps, angioedema or bronchospasm.

Ketorolac: Epidemiological evidence suggests that ketorolac may be associated with a high risk of serious gastrointestinal toxicity, relative to some other NSAIDs, especially when used outside the licensed indications and/ or for prolonged periods (see also section 4.1, 4.2 and 4.3).

The use of Ketorolac with concomitant NSAIDs including cyclooxygenase-2 selective inhibitors should be avoided.

Undesirable effects may be minimised by using the lowest effective dose for the shortest duration necessary to control symptoms (see section 4.2 and GI and cardiovascular risks below).

Gastrointestinal ulceration, bleeding and perforation

GI bleeding, ulceration or perforation, which can be fatal, has been reported with all NSAIDs including ketorolac therapy, at anytime during treatment, with or without warning symptoms or a previous history of serious GI events.

The elderly have an increased frequency of adverse reactions to NSAIDs, especially gastrointestinal bleeding and perforation which may be fatal. Debilitated patients seem to tolerate ulceration or bleeding less well than others. Most of the fatal gastrointestinal events associated with non-steroidal anti-inflammatory drugs occurred in the elderly and/or debilitated patients. The risk of GI bleeding, ulceration or perforation is higher with increasing NSAID doses, including ketoroloac, in patients with a history of ulcer, particularly if complicated with haemorrhage or perforation, and in the elderly. The risk of clinically serious gastrointestinal bleeding is dose dependent. These patients should commence treatment on the lowest dose available. Combination therapy with protective agents (e.g. misoprostol or proton pump inhibitors) should be considered for these patients, and also for patients requiring concomitant low dose aspirin, or other drugs likely to increase gastrointestinal risk (see section 4.5). This age-related risk of gastrointestinal bleeding and perforation is common to all NSAIDs. Compared to young adults, the elderly have an increased plasma half-life and reduced plasma clearance of ketorolac. A longer dosing interval is advisable (see section 4.2).

NSAIDs should be given with care to patients with a history of inflammatory bowel disease (ulcerative colitis, Crohn's disease) as these conditions may be exacerbated (see section 4.8). Patients with a history of GI toxicity, particularly when elderly, should report any unusual abdominal symptoms (especially GI bleeding) particularly in the initial stages of treatment. When GI bleeding or ulceration occurs in patients receiving Ketorolac, treatment should be withdrawn.

Caution should be advised in patients receiving concomitant medications which could increase the risk of ulceration or bleeding, such as oral corticosteroids, selective serotonin-reuptake inhibitors or anti-platelet agents such as aspirin (see section 4.5).

Use in patients taking anticoagulants such as warfarin is contraindicated (see section 4.3).

As with other NSAIDs the incidence and severity of gastrointestinal complications may increase with increasing dose and duration of treatment with Ketorolac. The risk of clinically serious gastrointestinal bleeding is dose-dependent. A history of peptic ulcer disease increases the possibility of developing serious gastrointestinal complications during Ketorolac therapy.

Haematological effects:

Patients with coagulation disorders should not receive Toradol. Patients on anticoagulation therapy may be at increased risk of bleeding if given Toradol concurrently. The concomitant use of ketorolac and prophylactic low dose heparin (2500 - 5000 units 12-hourly) and dextrans has not been studied extensively and may also be associated with an increased risk of bleeding. Patients already on anticoagulants or who require low-dose heparin should not receive ketorolac. Patients who are receiving other drug therapy that interferes with haemostasis should be carefully observed if Toradol is administered. In controlled clinical studies, the incidence of clinically significant postoperative bleeding was less than 1%.

Ketorolac inhibits platelet aggregation and prolongs bleeding time. In patients with normal bleeding function, bleeding times were raised, but not outside the normal range of 2 - 11 minutes. Unlike the prolonged effects from aspirin, platelet function returns to normal within 24 to 48 hours after ketorolac is discontinued.

Caution should be used where strict haemostasis is critical, e.g. in cosmetic or day-case surgery, resection of the prostate or tonsillectomy. Haematomas and 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 non-steroidal anti-inflammatory drugs that inhibit cyclo-oxygenase and the risk of bleeding, particularly in the elderly.

Skin reactions

Serious skin reactions, some of them fatal, including exfoliative dermatitis, Stevens-Johnson syndrome, and toxic epidermal necrolysis, have been reported very rarely in association with the use of NSAIDs (see section 4.8). Patients appear to be at highest risk for these reactions early in the course of therapy: the onset of the reactions occurring in the majority of cases within the first month of treatment. Toradol should be discontinued at the first appearance of skin rash, mucosal lesions, or any other sign of hypersensitivity.

SLE and mixed connective tissue disease:

In patients with systemic lupus erythematosus (SLE) and mixed connective tissue disorders there may be an increased risk of aseptic meningitis (see section 4.8).

Sodium/fluid retention in cardiovascular conditions and peripheral oedema

Caution is required in patients with a history of hypertension and /or heart failure as fluid retention and oedema have been reported in association with NSAID therapy.

Fluid retention, hypertension and peripheral oedema has been observed in some patients taking NSAIDs including Ketorolac and it should therefore be used with caution in patients with cardiac decompensation, hypertension or similar conditions.

Cardiovascular and cerebrovascular effects

Appropriate monitoring and advice are required for patients with a history of hypertension and/or mild to moderate congestive heart failure as fluid retention and oedema have been reported in association with NSAID therapy.

Clinical trial and epidemiological data suggest that use of coxibs and some NSAIDs (particularly at high doses) may be associated with a small increased risk of arterial thrombotic events (for example myocardial infarction or stroke). ). Although ketorolac has not shown to increase thrombotic events such as myocardial infarction, there are insufficient data to exclude such a risk for Ketorolac.

Patients with uncontrolled hypertension, congestive heart failure, established ischaemic heart disease, peripheral arterial disease, and/or cerebrovascular disease should only be treated with Ketorolac after careful consideration. Similar consideration should be made before initiating treatment of patients with risk factors for cardiovascular disease (e.g. hypertension, hyperlipidaemia, diabetes mellitus, and smoking).

Cardiovascular, Renal and Hepatic Impairment:

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 reaction 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. Renal function should be monitored in these patients. Discontinuation of NSAID therapy is typically followed by recovery to the pre-treatment state. Inadequate fluid/blood replacement during surgery, leading to hypovolaemia, 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 and creatinine and urine output is recommended until the patient is normovolaemic. In patients on renal dialysis, ketorolac clearance was reduced to approximately half the normal rate and terminal half-life increased approximately three-fold (see section 4.3).

Renal effects:

As with other NSAIDs Ketorolac should be used with caution in patients with impaired renal function or a history of kidney disease because it is a potent inhibitor of prostaglandin synthesis. Caution should be observed as renal toxicity has been seen with Ketorolac and other NSAIDs 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 Ketorolac or other NSAIDs may cause a dose-dependent reduction in renal prostaglandin formation and may precipitate overt renal decompensation or failure. Patients at greatest risk of this reaction are those with impaired renal function, hypovolaemia, heart failure, liver dysfunction, those taking diuretics and the elderly. Discontinuation of Ketorolac or other non-steroidal anti-inflammatory therapy is usually followed by recovery to the pre-treatment state.

As with other drugs that inhibit prostaglandin synthesis, elevations of serum urea, creatinine and potassium have been reported with ketorolac trometamol and may occur after one dose.

Patients with impaired renal function: Since ketorolac trometamol and its metabolites are excreted primarily by the kidney, patients with moderate to severe impairment of renal function (serum creatinine greater than 160 micromol/l) should not receive Toradol. Patients with lesser renal impairment should receive a reduced dose of ketorolac (not exceeding 60mg/day IM or IV) and their renal status should be closely monitored.

Use in patients with impaired liver function: Patients with impaired hepatic function from cirrhosis do not have any clinically important changes in ketorolac clearance or terminal half-life.

Borderline elevations of one or more liver function tests may occur. These abnormalities may be transient, may remain unchanged, or may progress with continued therapy. Meaningful elevations (greater than 3 times normal) of serum glutamate pyruvate transaminase (SGPT/ALT) or serum glutamate oxaloacetate transaminase (SGOT/AST) occurred in controlled clinical trials in less than 1% of patients. If clinical signs and symptoms consistent with liver disease develop, or if systemic manifestations occur, Toradol should be discontinued.

Anaphylactic (anaphylactoid) reactions

Anaphylactic (anaphylactoid) reactions (including, but not limited to, anaphylaxis, bronchospasm, flushing, rash, hypotension, laryngeal oedema and angioedema) may occur in patients with or without a history of hypersensitivity to aspirin other NSAIDs or Ketorolac. 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, Ketorolac 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.

Precautions related to fertility

The use of Toradol, as with any drug known to inhibit cyclooxygenase/prostaglandin synthesis, may impair fertility and is not recommended in women attempting to conceive. In women who have difficulty conceiving or are undergoing investigation of fertility, withdrawal of Toradol should be considered.

Fluid retention and oedema

Fluid retention, hypertension and oedema have been reported with the use of Ketorolac and it should therefore be used with caution in patients with cardiac decompensation, hypertension or similar conditions.

Caution is advised when methotrexate is administered concurrently since some prostaglandin synthesis-inhibiting drugs have been reported to reduce the clearance of methotrexate, and thus possibly enhance its toxicity.

Pediatric Use:

Ketorolac tablets are not recommended for use in children. Ketorolac given parenterally is not recommended in children younger than 2 years of age.

Drug Abuse and Dependence

Ketorolac is devoid of addictive potential. No withdrawal symptoms have been observed following abrupt discontinuation of Ketorolac.

Ketorolac is highly bound to human plasma protein (mean 99.2%) and binding is concentration-independent.

The following medicinal products are NOT to be co-administered with Toradol:

Toradol should not be used with ASA or other NSAIDs including cyclooxygenase-2 selective inhibitors as the risk of inducing serious NSAID-related adverse events may be increased (see section 4.3).

Ketorolac inhibits platelet aggregation, reduces thromboxane concentrations and prolongs bleeding time. Unlike the prolonged effects from aspirin, platelet function returns to normal within 24-48 hours after Ketorolac is discontinued.

Toradol is contraindicated in combination with anti-coagulants, such as warfarin since co-administration of NSAIDs and anticoagulants may cause an enhanced anti-coagulant effect (see section 4.3).

Although studies do not indicate a significant interaction between Ketorolac and warfarin or heparin the concurrent use of Ketorolac and therapy that affects haemostasis, including therapeutic doses of anticoagulation therapy (warfarin) prophylactic low-dose heparin (2500-5000 units 12-hourly) and dextrans may be associated with an increased risk of bleeding.

Inhibition of renal lithium clearance, leading to an increase in plasma lithium concentration, has been reported with some prostaglandin synthesis-inhibiting drugs. Cases of increased lithium plasma concentrations during Ketorolac therapy have been reported.

Probenecid should not be administered concurrently with ketorolac because of increases in ketorolac plasma concentrations and half-life.

NSAIDs should not be used for 8 to 12 days after mifepristone administration as NSAIDs can reduce the effects of mifepristone.

The following medicinal products, in combination with Toradol, are to be co-administered with caution:

As with all NSAIDs, caution should be taken when co-administering with corticosteroids because of the increased risk of gastro-intestinal ulceration or bleeding (see section 4.4).

There is an increased risk of gastrointestinal bleeding (see section 4.4) when antiplatelet agents and selective serotonin reuptake inhibitors (SSRIs) are combined with NSAIDs.

When ketorolac is administered concurrently with oxpentifylline there is an increased tendency to bleeding.

Some prostaglandin synthesis-inhibiting drugs have been reported to reduce the clearance of methotrexate, and thus possibly enhance its toxicity.

Ketorolac tromethamine does not alter digoxin protein binding. In vitro studies indicate that at therapeutic concentrations of salicylate (300μg/ml), the binding of ketorolac was reduced from approximately 99.2% to 97.5% representing a potential twofold increase in unbound ketorolac plama concentrations. Therapeutic concentrations of digoxin, warfarin, ibuprofen, naproxen, piroxicam, acetaminophen, phenytoin and tolbutamide did not alter ketorolac protein binding.

Ketorolac Solution for injection reduced the diuretic response to furosemide in normovolemic healthy subjects by approximately 20% so particular care should be taken in patients with cardiac decompensation.

Co-administration with diuretics can lead to a reduced diuretic effect, and increase the risk of nephrotoxicity of NSAIDs.

As with all NSAIDs caution is advised when ciclosporin is co-administered because of the increased risk of nephrotoxicity.

There is a possible risk of nephrotoxicity when NSAIDs are given with tacrolimus.

NSAIDs may reduce the effect of diuretics and antihypertensive medicinal products, such as beta-blockers. The risk of acute renal insufficiency, which is usually reversible, may be increased in some patients with compromised renal function (e.g. dehydrated patients or elderly patients) when ACE inhibitors and/or angiotensin II receptor antagonists are combined with NSAIDs. Therefore, the combination should be administered with caution, especially in the elderly. Patients should be adequately titrated and consideration should be given to monitoring renal function after initiation of concomitant therapy, and periodically thereafter.

NSAIDs may exacerbate cardiac failure, reduce GFR and increase plasma cardiac glycoside levels when co-administered with cardiac glycosides.

Ketorolac has been shown to reduce the need for concomitant opioid analgesia when it is given for the relief of postoperative pain.

Oral administration of Ketorolac Tablets after a high-fat meal resulted in decreased peak and delayed time-to-peak concentrations of ketorolac by about 1 hour. Antacids did not affect the extent of absorption.

Animal data indicate that NSAIDs can increase the risk of convulsions associated with quinolone antibiotics. Patients taking NSAIDs and quinolones may have an increased risk of developing convulsions.

NSAIDs given with zidovudine increase the risk of haematological toxicity. There is evidence of an increased risk of haemarthroses and haematoma in HIV (+) haemophiliacs receiving concurrent treatment with zidovudine and ibuprofen.

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

Pregnancy

The safety of Toradol during human pregnancy has not been established.

There was no evidence of teratogenicity in rats or rabbits studied at maternally-toxic doses of ketorolac. Prolongation of the gestation period and/or delayed parturition were seen in the rat. Congenital abnormalities have been reported in association with NSAID administration in man; however, these are low in frequency and do not appear to follow any discernible pattern. In view of the known effects of NSAIDs on the foetal cardiovascular system (risk of closure of the ductus arteriosus) ketorolac is contraindicated during pregnancy, labour or delivery.

See section 4.4 regarding female fertility.

Ketorolac crosses the placenta to the extent of approximately 10%.

Labour and Delivery:

Ketorolac is contraindicated in labour and delivery because, through its prostaglandin synthesis inhibitory effect it may adversely affect foetal circulation and inhibit uterine contractions, thus increasing the risk of uterine haemorrhage.

There may be increased bleeding tendency in both mother and child (see section 4.3)

Nursing Mothers: Ketorolac and its metabolites have been shown to pass into the foetus and milk of animals. Ketorolac has been detected in human milk at low concentrations, therefore ketorolac is contra-indicated in mothers who are breast-feeding.

Some patients may experience drowsiness, dizziness, vertigo, insomnia, fatigue, visual disturbances or depression with the use of Toradol. If patients experience these, or other similar undesirable effects, they should not drive or operate machinery.

Post Marketing

The following undesirable effects may occur in patients receiving Ketorolac; frequencies of reported events are not known, because they were reported voluntarily from a population of uncertain size.

Gastro-intestinal disorders: The most commonly observed adverse events are gastrointestinal in nature. Peptic ulcers, ulcer, perforation or GI bleeding, sometimes fatal, particularly in the elderly, may occur (see section 4.4). Nausea, vomiting, diarrhoea, constipation, dyspepsia, abdominal pain / discomfort, melaena, haematemesis, stomatitis, ulcerative stomatitis, eructation, flatulence, oesophagitis, gastrointestinal ulceration, rectal bleeding, pancreatitis, dry mouth, fullness, exacerbation of colitis and Crohn's disease (see section 4.4) have been reported following administration. Less frequently, gastritis has been observed.

Infection: meningitis aseptic (especially in patients with existing auto-immune disorders, such as systemic lupus erythematosus, mixed connective tissue disease), with symptoms such as stiff neck, headache, nausea, vomiting, fever or disorientation (see section 4.4)

Blood and Lymphatic System Disorders: thrombocytopenia

Additionally purpura, neutropenia, agranulocytosis, aplastic anaemia and haemolytic anaemia have been observed.

Immune System Disorders: anaphylaxis, anaphylactoid reactions, anaphylactoid reactions like anaphylaxis, may have a fatal outcome, hypersensitivity reactions such as bronchospasm flushing, rash, hypotension, laryngeal oedema.

These may also occur in individuals with a history of angioedema, bronchospastic reactivity (e.g. asthma and nasal polyps).

Metabolic and Nutrition Disorders: anorexia, hyperkalaemia, hyponatraemia

Psychiatric Disorders: abnormal thinking, depression, insomnia, anxiety, nervousness, psychotic reactions, abnormal dreams, hallucinations, euphoria, concentration ability impaired, drowsiness.

Confusion and stimulation have been observed.

Nervous system disorders: headache, dizziness, convulsions, paresthesia, hyperkinesias, taste abnormality.

Eye Disorders: abnormal vision, visual disturbances, optic neuritis.

Ear Disorders: tinnitus, hearing loss, vertigo.

Renal and Urinary Disorders: acute renal failure, increased urinary frequency, interstitial nephritis, nephrotic syndrome, urinary retention, oliguria, haemolytic uremic syndrome, flank pain(with or without haematuria +- azotemia). As with other drugs that inhibit renal prostaglandin synthesis signs of renal impairment, such as, but not limited to elevations of creatinine and potassium can occur after one dose of Ketorolac.

Cardiac Disorders: palpitations, bradycardia, cardiac failure.

Vascular disorders: hypertension, hypotension, haematoma, flushing, pallor, postoperative wound haemorrhage.

Clinical trial and epidemiological data suggest that use of coxibs and some NSAIDs (particularly at high doses) may be associated with a small increased risk of arterial thrombotic events (for example myocardial infarction or stroke). Although ketorolac has not shown to increase thrombotic events, such as myocardial infarction, there are insufficient data to exclude such a risk with ketorolac.

Reproductive System and Breast Disorders: female infertility.

Respiratory, Thoracic and Mediastinal Disorders: asthma, dyspnoea, pulmonary oedema.

Additionally epistaxis has been observed.

Hepatobiliary Disorders: hepatitis, cholestatic jaundice, liver failure.

Skin and Subcutaneous Tissue Disorders: exfoliative dermatitis, maculopapular rash, pruritus, urticaria, purpura, angioedema, sweating, bullous reactions including Stevens-Johnson syndrome and toxic epidermal necrolysis (very rare).

Additionally erythema multiforme and skin photosensitivity has been observed.

Musculoskeletal and Connective Tissue Disorders: myalgia, functional disorder.

General Disorders and Administration Site Condition: excessive thirst, asthenia, oedema, fever, chest pain. Additionally, malaise, fatigue and weight gain has been observed.

Investigations: bleeding time prolonged, serum urea increased, creatinine increased, abnormal liver function tests.

Laboratory Abnormalities

See Section Post Marketing (Undesirable Effects).

Symptoms and signs

Single overdoses of Ketorolac 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.

Headache, epigastric pain, disorientation, excitation, drowsiness, dizziness, tinnitus, and fainting, have also been observed. Rare cases of diarrhoea and occasional convulsions have been reported.

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 NSAIDs overdose. There are no specific antidotes. Dialysis does not significantly clear ketorolac from the blood stream.

Within one hour of ingestion of a potentially toxic amount, activated charcoal should be considered. Alternatively, in adults, gastric lavage should be considered with one hour of ingestion of a potentially life-threatening overdose.

Good urine output should be ensured. Renal and liver function should be closely monitored. Patients should be observed for at least four hours after ingestion of potentially toxic amounts. Frequent or prolonged convulsions should be treated with intravenous diazepam. Other measures may be indicated by the patient's clinical condition.

Ketorolac trometamol is a non-narcotic analgesic. It is a nonsteroidal anti-inflammatory agent that exhibits anti-inflammatory and weak antipyretic activity.

Ketorolac trometamol inhibits the synthesis of prostaglandins and is considered a peripherally acting analgesic. It does not have known effects on opiate receptors.

No evidence of respiratory depression has been observed after administration of ketorolac trometamol in controlled clinical trials. Ketorolac trometamol does not cause pupil constriction.

Ketorolac trometamol is rapidly and completely absorbed following oral administration with a peak plasma concentration of 0.87mcg/ml occurring 50 minutes after a single 10mg dose. The terminal plasma elimination half-life averages 5.4 hours (S.D = 1.0) in healthy subjects. In elderly subjects (mean age 72) it is 6.2 hours (S.D = 1.0). More than 99% of the ketorolac in plasma is protein bound.

The pharmacokinetics of ketorolac in man following single or multiple doses are linear. Steady state plasma levels are achieved after 1 day of Q.I.D. dosing. No changes occurred with chronic dosing. Following a single intravenous dose, the volume of distribution is 0.25 l/kg, the half-life is 5 hours and the clearance 0.55ml/min/kg. The primary route of excretion of ketorolac and its metabolites (conjugates and the p-hydroxymetabolite) is in the urine (91.4%) and the remainder is excreted in the faeces.

A high fat diet decreased the rate, but not the extent of absorption, while antacid had no effect on ketorolac absorption.

None stated.

Tablet core:

Microcrystalline cellulose (E460)

Lactose monohydrate

Magnesium stearate

Film-coating mixture:

Opadry white YS-1R-7002 containing:

Hypromellose,

Titanium dioxide (E171)

Macrogol

Printing ink:

Opacode Black-S-1-27794 containing:

Shellac, modified

Iron oxide black (E172)

Propylene glycol

Purified water

None known.

3 years.

Toradol tablets should be kept in their original packaging to protect them from moisture and light.

White HDPE bottles with polypropylene screw containers containing 50, 56, 100, 250 or 500 tablets.

Polypropylene securitainers containing 50, 56, 100, 250 or 500 tablets.

Amber or white OPA/PVC/aluminium foil blister packs in outer cardboard carton containing 4, 20, 28, 50, 56, 100, 250 or 500 tablets.

None stated.

Roche Products Limited

6 Falcon Way

Shire Park

Welwyn Garden City

AL7 1TW

United Kingdom

PL 0031/0482

24/02/2009

24 June 2011

POM