From the Guidelines
Toradol (ketorolac) should be avoided in patients with cirrhosis due to significant risks, as it can worsen hepatic function, increase bleeding risk, reduce renal blood flow, and precipitate hepatorenal syndrome. This NSAID is contraindicated in advanced liver disease because cirrhotic patients have impaired drug metabolism, leading to increased blood levels and prolonged half-life of ketorolac 1. The medication can also promote sodium and fluid retention, potentially worsening ascites and edema common in cirrhosis.
For pain management in cirrhotic patients, safer alternatives include:
- Acetaminophen (limited to 2-3 grams daily in most cases) 1
- Low-dose opioids with careful monitoring
- Non-pharmacological approaches
If pain medication is necessary, consultation with hepatology and pharmacy is recommended to determine the safest option based on the patient's specific cirrhosis severity and comorbidities. It is also important to avoid other nephrotoxic drugs, such as nonsteroidal anti-inflammatory drugs, and hepatotoxic drugs, such as excessive acetaminophen (>2 g/d) and certain herbal supplements 1.
Key considerations for managing pain in cirrhotic patients include:
- Avoiding NSAIDs and other nephrotoxic drugs
- Limiting acetaminophen use to recommended doses
- Monitoring for signs of hepatorenal syndrome and other complications
- Consulting with hepatology and pharmacy experts to determine the safest pain management options.
From the FDA Drug Label
Hepatic Effect Ketorolac tromethamine should be used with caution in patients with impaired hepatic function or a history of liver disease Borderline elevations of one or more liver tests may occur in up to 15% of patients taking NSAIDs including ketorolac tromethamine. Notable elevations of ALT or AST (approximately three or more times the upper limit of normal) have been reported in approximately 1% of patients in clinical trials with NSAIDs. In addition, rare cases of severe hepatic reactions, including jaundice and fatal fulminant hepatitis, liver necrosis and hepatic failure, some of them with fatal outcomes have been reported A patient with symptoms and/or signs suggesting liver dysfunction, or in whom an abnormal liver test has occurred, should be evaluated for evidence of the development of a more severe hepatic reaction while on therapy with ketorolac tromethamine. If clinical signs and symptoms consistent with liver disease develop, or if systemic manifestations occur (e.g., eosinophilia, rash, etc.), ketorolac tromethamine should be discontinued.
Key Considerations:
- Ketorolac tromethamine should be used with caution in patients with a history of liver disease, including cirrhosis.
- Patients with a history of liver disease are at risk for worsening liver function or severe hepatic reactions.
- Monitoring of liver function is recommended in patients with a history of liver disease.
- Ketorolac tromethamine should be discontinued if signs or symptoms of liver disease develop. 2
From the Research
Considerations for Using Toradol (Ketorolac) in Patients with a History of Cirrhosis
- Toradol, also known as Ketorolac, is a non-steroidal anti-inflammatory drug (NSAID) that should be used with caution in patients with a history of cirrhosis due to the risk of renal impairment, hepatorenal syndrome, and gastrointestinal hemorrhage 3, 4, 5.
- The use of NSAIDs, including Toradol, is generally not recommended in patients with cirrhosis, especially in advanced cases, due to the potential for worsening renal function, blunting diuretic response, and increasing the risk of portal hypertensive and peptic ulcer bleeding 4, 5.
- If Toradol is considered necessary for a patient with a history of cirrhosis, it is essential to carefully weigh the potential benefits against the risks and to monitor the patient closely for any adverse effects 3, 6.
- Alternative analgesic options, such as acetaminophen (in recommended doses of 2-3 grams daily) or gabapentin, may be safer for patients with cirrhosis 3, 4, 5.
- It is crucial to consider the individual patient's circumstances, including the severity of their liver disease, history of opioid dependence, and potential drug interactions, when deciding on an analgesic regimen 3, 6.