Critical
Ketorolac × Nimesulide
Non-steroidal anti-inflammatory drugs (NSAIDs)×Antiinflammatory and antirheumatic agents, non-steroids. Other NSAIDs
Mechanism
Ketorolac is a potent non-selective NSAID; nimesulide is a selective COX-2 inhibitor. Despite different selectivity, gastrointestinal and renal effects are additive. FDA Toradol Section 4.3 specifically lists all NSAIDs as contraindications.
Symptoms
Black or tarry stools (melena), vomiting blood or coffee-ground material, epigastric pain. Acute kidney injury and a rise in blood pressure are also possible. Risk of bleeding multiplies in patients over 65 and with prior peptic ulcer disease.
Management
The combination is not prescribed. Use one NSAID at the minimum effective dose with PPI cover (pantoprazole). Alternative: paracetamol as baseline analgesia.