From the FDA Drug Label
Ketorolac tromethamine is contraindicated in patients with advanced renal impairment or in patients at risk for renal failure due to volume depletion Ketorolac tromethamine is contraindicated in patients with serum creatinine concentrations indicating advanced renal impairment
Toradol (ketorolac) is contraindicated in patients with End-Stage Renal Disease (ESRD) on dialysis due to the risk of renal failure and advanced renal impairment.
- The drug label explicitly states that ketorolac tromethamine is contraindicated in patients with advanced renal impairment or those at risk for renal failure.
- Patients with ESRD on dialysis have advanced renal impairment, making the use of ketorolac tromethamine contraindicated 1.
From the Research
Toradol (ketorolac) should generally be avoided in patients with End-Stage Renal Disease (ESRD) on dialysis. This medication is contraindicated in advanced renal impairment because it can worsen kidney function and increase the risk of serious adverse effects. Ketorolac is primarily eliminated by the kidneys, and when kidney function is severely compromised, as in ESRD, the drug and its metabolites can accumulate to toxic levels. This accumulation increases the risk of gastrointestinal bleeding, cardiovascular events, and further kidney damage.
For ESRD patients requiring pain management, alternative analgesics such as acetaminophen, certain opioids with dose adjustments (like hydromorphone or fentanyl), or non-pharmacological pain management strategies would be more appropriate, as suggested by 2. If an NSAID is absolutely necessary for a specific clinical situation, it should only be used under close supervision, with significantly reduced dosing, for the shortest duration possible, and with careful monitoring for adverse effects.
The fundamental concern is that NSAIDs like ketorolac inhibit prostaglandin synthesis, which can reduce renal blood flow and further compromise the already limited kidney function in ESRD patients. A recent study 3 highlights the need for caution with NSAIDs in ESRD patients, emphasizing the importance of weighing the benefits against the potential risks. Another study 4 notes the variability in prescribing patterns for analgesics in patients with advanced CKD, suggesting a need for more guidance on optimal pain management strategies in this population.
Key considerations for managing pain in ESRD patients on dialysis include:
- Avoiding NSAIDs like toradol due to the risk of worsening kidney function and adverse effects
- Using alternative analgesics such as acetaminophen or certain opioids with caution and dose adjustments
- Considering non-pharmacological pain management strategies
- Close monitoring for adverse effects when any analgesic is used in this vulnerable population, as emphasized by 5 and 6.