What are the considerations for using Toradol (Ketorolac) in patients with impaired renal function undergoing dialysis?

From the Guidelines

Toradol (ketorolac) should be avoided in patients with impaired renal function undergoing dialysis due to significant safety concerns, as recommended by the most recent and highest quality study 1. When considering the use of Toradol in dialysis patients, several factors must be taken into account to minimize risks and ensure optimal pain management.

• The primary concern is the potential for renal toxicity and accumulation of the drug, as ketorolac is primarily eliminated by the kidneys (up to 90%) 1.
• Additionally, ketorolac can reduce prostaglandin synthesis, which may impair renal blood flow regulation and potentially cause further kidney damage.
• Alternative analgesics such as acetaminophen, low-dose opioids, or certain adjuvant medications should be considered instead for pain management in this vulnerable population.
• If the use of ketorolac is deemed necessary, the dose should be reduced by 50% with a maximum daily dose of 60 mg, and the duration should be limited to no more than 2-3 days.
• Close monitoring of renal function, urine output, and signs of bleeding is essential if ketorolac must be used in patients with any degree of renal impairment. The study published in the BMJ in 2024 1 provides the most recent and highest quality evidence for the management of pain in patients with impaired renal function, and its recommendations should be prioritized to minimize morbidity, mortality, and improve quality of life.

From the FDA Drug Label

Ketorolac tromethamine is contraindicated in patients with serum creatinine concentrations indicating advanced renal impairment 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 is contraindicated in patients with advanced renal impairment. For patients undergoing dialysis, this implies that Toradol (Ketorolac) should not be given due to the risk of acute renal decompensation or failure.

• The use of ketorolac tromethamine in patients with impaired renal function requires careful assessment of the risks and benefits.
• Patients with underlying renal insufficiency are at increased risk of developing acute renal decompensation or failure.
• The drug is a potent inhibitor of prostaglandin synthesis, which can further compromise renal function in these patients 2.

From the Research

Considerations for Using Toradol in Dialysis Patients

• The use of Toradol (Ketorolac) in patients with impaired renal function undergoing dialysis requires careful consideration due to the potential risks of nephrotoxicity and other adverse effects 3, 4.
• Nonsteroidal anti-inflammatory drugs (NSAIDs), including Toradol, have been associated with acute kidney injury, progressive loss of glomerular filtration rate, electrolyte derangements, and hypervolemia in patients with chronic kidney disease (CKD) 4.
• However, some studies suggest that limited use of NSAIDs, including Toradol, may be justified in dialysis patients due to the difficulty in achieving adequate pain control and the potential benefits of reducing opioid use 3, 5.
• The pharmacokinetics and pharmacodynamics of Toradol have been extensively evaluated, and it has been shown to be effective in managing moderate to severe pain in various clinical settings, including postoperative pain and renal colic 5, 6.
• When used in accordance with current dosage guidelines, Toradol has a tolerability profile similar to that of other NSAIDs, with most clinically important adverse events affecting the gastrointestinal tract and/or renal or hematological function 5.

Key Findings and Recommendations

• The evidence directly examining the impact of NSAIDs, including Toradol, on long-term outcomes in end-stage kidney disease (ESKD) patients is limited, and further study is warranted 3.
• In patients with CKD, the risk of nephrotoxicity syndromes associated with NSAID use differs between levels of glomerular filtration rate, and careful consideration of individual risk factors is necessary 4.
• Toradol may be a useful alternative or adjuvant to opioids in patients with moderate to severe pain, but its use should be carefully monitored, and dosage guidelines should be followed to minimize the risk of adverse effects 5, 6.