Gastrointestinal Risks of Intramuscular NSAIDs

Mechanism and Risk Factors

• NSAIDs, including ketorolac, cause gastrointestinal damage primarily through systemic inhibition of prostaglandin synthesis, not through direct contact with the gastric mucosa 1
• The systemic effect occurs regardless of the route of administration (oral, intramuscular, or intravenous) 1, 2
• Concomitant use of aspirin with any NSAID, including IM ketorolac, increases GI bleeding risk more than 10-fold compared to using either agent alone 3

Strategies to Reduce GI Risk

• Use the lowest effective dose for the shortest duration possible 2, 3
• Consider gastroprotective co-therapy with proton pump inhibitors (PPIs) for high-risk patients 1, 2
• Misoprostol co-therapy reduces the incidence of gastroduodenal ulcers (74% reduction in gastric ulcers and 53% reduction in duodenal ulcers compared to placebo) 1
• H. pylori eradication before starting NSAID therapy may reduce risk in some patients 2, 3

Alternative Approaches for Pain Management

• For patients at high risk of GI complications, consider non-NSAID analgesics when possible 2
• If an NSAID is necessary for patients with high GI risk, consider using a COX-2 selective inhibitor with a PPI 4, 3
• For patients with both high GI and CV risk, naproxen plus a PPI may offer the best balance of risks 3