Ketorolac Shortage: A Briefing for Providers and Prescribers

Ketorolac Tromethamine — the cornerstone injectable NSAID for acute pain management — has been a persistent supply chain challenge since 2020. For providers in emergency medicine, surgery, anesthesiology, and primary care, understanding the current availability picture and having contingency plans is essential for patient care continuity.

This briefing covers the shortage timeline, prescribing implications, alternative therapies, cost considerations, and tools to help your patients access Ketorolac when supply is tight.

Shortage Timeline: How We Got Here

Ketorolac injection first appeared on the ASHP Drug Shortage list in 2020. Key milestones include:

• 2020: Initial supply disruptions reported across multiple manufacturers. Hospira (Pfizer) and Fresenius Kabi were the primary producers of Ketorolac injection in the U.S.
• 2021-2022: Ongoing manufacturing quality issues at Hospira led to intermittent production halts. Fresenius Kabi experienced demand surges it could not fully meet. Other manufacturers — including Hikma and Athenex — stepped in but with limited capacity.
• 2023: Hospira resolved a production issue and resumed shipping in mid-2023, but certain vial sizes (particularly the 30 mg/mL 2 mL IM vials) remained on backorder through much of the year.
• 2024: Supply continued to improve with multiple manufacturers back online. ASHP posted updates through August 2024, indicating that availability was recovering but not yet fully normalized across all formulations.
• 2025-2026: The situation has stabilized for most formulations. Oral tablets and ophthalmic preparations have remained consistently available. Some injectable SKUs may still see intermittent tightness, particularly during demand spikes (e.g., flu season, surgical volume increases).

Prescribing Implications

The shortage has several practical implications for prescribers:

Formulary Adjustments

Many hospital pharmacy and therapeutics (P&T) committees have added or prioritized alternative injectable analgesics on their formularies. If your institution has restricted Ketorolac or moved to an allocation model, familiarize yourself with the approved alternatives.

Route of Administration Flexibility

When injectable Ketorolac is unavailable, consider whether the oral or intranasal route is appropriate for your patient:

• Oral Ketorolac (10 mg tablets): Appropriate for patients who can take oral medications and are transitioning from parenteral therapy. Supply is generally stable. Remember: oral therapy should only follow IV/IM Ketorolac, and total combined duration must not exceed 5 days.
• Sprix nasal spray (15.75 mg/spray): Delivers ketorolac via the nasal mucosa with rapid absorption (peak plasma in 30-45 minutes). Available by prescription, though retail availability varies and cost without insurance is high ($1,700-$2,200).

Duration and Dosing Reminders

Given the boxed warning, it bears repeating:

• Total Ketorolac therapy (all routes combined) must not exceed 5 days
• Elderly patients (≥65): reduce maximum dose to 60 mg/day IV/IM
• Patients weighing <50 kg: reduce maximum dose to 60 mg/day IV/IM
• Renal impairment (CrCl <30 mL/min): contraindicated
• Oral Ketorolac should only be used as continuation therapy after IV/IM dosing

For a full review of Ketorolac pharmacology and safety, see our drug interactions guide and side effects overview.

Current Availability Picture

As of early 2026:

• Ketorolac 15 mg/mL and 30 mg/mL IV injection: Generally available from multiple generic manufacturers. Spot shortages may occur.
• Ketorolac 60 mg/2 mL IM injection: This SKU has been the most frequently affected by shortages. Check current stock with your distributor or use Medfinder for Providers.
• Ketorolac 10 mg oral tablets: Widely available. Generic pricing is low ($10-$25 retail, as low as $10-$13 with discount coupons).
• Sprix nasal spray: Available but may require prior authorization for insurance coverage. High cash price.

Alternative Analgesics for Acute Pain

When Ketorolac is unavailable, consider these evidence-based alternatives:

Injectable Alternatives

• Diclofenac IV (Dyloject): 37.5 mg IV bolus over 15 seconds. The most direct pharmacologic substitute for injectable Ketorolac. Available since FDA approval in 2014, though availability varies by institution.
• Ibuprofen IV (Caldolor): 400-800 mg IV over 30 minutes every 6 hours. Well-studied for perioperative analgesia. Can be used as a Ketorolac substitute in multimodal pain protocols.
• Acetaminophen IV (Ofirmev): 1g IV every 6 hours. Not an NSAID, but provides additive analgesia in multimodal regimens. No anti-inflammatory effect.

Oral Alternatives

• Ibuprofen 600-800 mg PO every 6-8 hours: First-line oral NSAID alternative. Widely available and inexpensive.
• Naproxen 500 mg PO every 12 hours: Longer half-life allows less frequent dosing. Good for patients being discharged.
• Celecoxib 200-400 mg PO: COX-2 selective. Lower GI risk profile. Good alternative for patients with GI history.
• Diclofenac 50 mg PO every 8 hours: Similar anti-inflammatory potency to Ketorolac. Also available as topical gel.

For more on alternatives, see our alternatives guide.

Cost and Access Considerations

For patients being discharged with a Ketorolac oral prescription:

• Generic Ketorolac 10 mg tablets are among the most affordable prescription NSAIDs, typically $10-$13 with a coupon for a short course.
• Most Medicare Part D and commercial plans cover generic Ketorolac with minimal copays.
• Discount cards from GoodRx, SingleCare, and other services can reduce out-of-pocket costs for uninsured patients.
• Sprix nasal spray is significantly more expensive and may face insurance barriers. Prior authorization is often required.

Direct patients to our savings guide or the provider guide to patient savings for more details.

Tools and Resources

Several tools can help your practice and your patients navigate Ketorolac availability:

• Medfinder for Providers: Check real-time Ketorolac availability at pharmacies in your area. Useful for directing patients to pharmacies with confirmed stock.
• ASHP Drug Shortage Resource Center: Track Ketorolac injection shortage status and manufacturer updates.
• FDA Drug Shortage Database: Monitor official shortage reports and estimated resupply dates.
• Institutional pharmacy alerts: Work with your pharmacy department to set up proactive alerts when Ketorolac stock falls below critical thresholds.

Looking Ahead

The Ketorolac injection shortage is a symptom of broader challenges in the generic injectable pharmaceutical supply chain — limited manufacturers, thin profit margins, and fragile production infrastructure. While the acute phase of this shortage appears to be subsiding, providers should maintain familiarity with alternative analgesic protocols.

The growing availability of injectable alternatives like Dyloject and Caldolor provides a safety net, and the continued expansion of multimodal analgesia protocols reduces reliance on any single agent.

Final Thoughts

Ketorolac remains an essential tool in acute pain management, but supply reliability is not guaranteed. By staying informed about shortage status, maintaining flexible prescribing protocols, and leveraging tools like Medfinder for Providers, you can continue to deliver effective pain management to your patients — even when supply is tight.

For patient-facing information to share, see our patient shortage update and guide to finding Ketorolac.