Can a patient with impaired renal function receive a ketorolac injection?

From the Guidelines

Ketorolac injection should be used with caution in patients with impaired renal function, and the dose should be reduced by 50% in patients with moderate renal impairment (GFR 30-59 mL/min/1.73m²), with a maximum treatment duration of 2 days. For patients with severe renal impairment, ketorolac use is generally not recommended due to the increased risk of adverse effects, particularly gastrointestinal bleeding and acute kidney injury, as ketorolac is primarily eliminated by the kidneys 1. The use of ketorolac in patients with impaired renal function requires careful consideration of the potential risks and benefits, and alternative pain management options should be considered, such as acetaminophen or opioids, depending on the severity of pain and other clinical factors 1. Some key points to consider when using ketorolac in patients with impaired renal function include:

• Reduced kidney function can lead to accumulation of the drug, increasing the risk of adverse effects
• Ketorolac can increase the risk of gastrointestinal bleeding and acute kidney injury
• Alternative pain management options, such as acetaminophen or opioids, may be safer and more effective in patients with impaired renal function
• If an NSAID is absolutely necessary, consider using a different NSAID with less renal impact, such as ibuprofen, at a reduced dose and for a short duration, while closely monitoring renal function 1. It is essential to weigh the potential benefits of ketorolac against the potential risks and to closely monitor patients with impaired renal function for signs of adverse effects, such as gastrointestinal bleeding or acute kidney injury 1.

From the FDA Drug Label

Ketorolac tromethamine is contraindicated in patients with serum creatinine concentrations indicating advanced renal impairment (see CONTRAINDICATIONS). Ketorolac tromethamine 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 Because patients with underlying renal insufficiency are at increased risk of developing acute renal decompensation or failure, the risks and benefits should be assessed prior to giving ketorolac tromethamine to these patients.

Ketorolac tromethamine should not be given to patients with advanced renal impairment. For patients with impaired renal function, ketorolac tromethamine should be used with caution and the risks and benefits should be assessed prior to administration 2.

• The recommended dose for renally impaired patients is 15 mg ketorolac tromethamine injection every 6 hours, with a maximum daily dose of 60 mg 2.
• Patients with impaired renal function should be closely monitored.
• Alternative therapies should be considered for high-risk patients, including those with impaired renal function 2 2.

From the Research

Administration of Ketorolac in Patients with Impaired Renal Function

• Patients with impaired renal function should exercise caution when receiving ketorolac injections, as the drug is excreted almost entirely by the kidney 3.
• The use of ketorolac in patients with underlying renal insufficiency may require an adjustment of the dosing interval or avoidance of the medication altogether 3.
• Short-term administration of ketorolac can be associated with reversible oliguric renal insufficiency, and its use should be avoided in patients at high risk for toxicity induced by nonsteroidal anti-inflammatory drugs 4.

Risk Factors for Renal Dysfunction

• Certain risk factors, such as advanced age, cirrhosis, volume depletion, congestive heart failure, gastrointestinal bleeding, and preexisting mild renal dysfunction, make individual patients more susceptible to the renal effects of NSAIDs, including ketorolac 5.
• The risk of acute renal failure associated with ketorolac is higher in patients who receive the drug for more than 5 days 6.
• Ketorolac use has been identified as a potential risk factor for renal dysfunction after live-donor nephrectomy, with patients who received ketorolac having a lower glomerular filtration rate (GFR) at 1 year after surgery compared to those who did not receive the drug 7.

Considerations for Ketorolac Administration

• Close attention to urine output and parameters of renal function must be maintained when administering ketorolac to patients with impaired renal function 3.
• The use of ketorolac should be avoided in patients who have conditions that predispose to NSAID nephrotoxicity 3.
• Patients who receive ketorolac should be monitored for signs and symptoms of acute renal failure, including significant increases in blood urea nitrogen, serum creatinine, and peripheral edema 5.