What is the next step for analgesia in a patient with a symptomatic kidney stone who has recurrent pain after receiving 50 mg of Toradol (ketorolac)?

Management of Recurrent Pain After Ketorolac in Kidney Stone Patient

For a patient with symptomatic kidney stone who has recurrent pain after receiving 50 mg of Toradol (ketorolac), the next step in analgesia should be administration of an opioid analgesic.

Rationale for Opioid Administration

Ketorolac (Toradol) is a potent NSAID that has reached its maximum recommended dose in this patient. According to the FDA drug label, ketorolac has specific dosing limitations:

• The maximum daily dose should not exceed 120 mg for patients under 65 years 1
• For single-dose treatment, 60 mg IM or 30 mg IV is the maximum recommended dose 1
• For multiple-dose treatment, 30 mg every 6 hours is recommended 1

Since the patient has already received 50 mg of ketorolac and is experiencing recurrent pain, the next appropriate step is to transition to opioid analgesia rather than administering additional ketorolac, which could increase the risk of adverse effects.

Specific Recommendations

1. Administer a short-acting opioid analgesic

   • Morphine 5-15 mg IV is appropriate for opioid-naïve patients 2
   • Reassess pain every 15 minutes after IV administration 2
   • Titrate dose based on response and side effects

2. Avoid additional ketorolac

   • The patient has already received a substantial dose of ketorolac
   • Additional NSAID administration increases risk of renal, GI, and cardiac toxicities 2, 3
   • Ketorolac therapy should not exceed 5 days total 1

Monitoring and Follow-up

• Assess efficacy and side effects every 15 minutes for IV opioids 2
• If pain remains unchanged or increases after initial dose, administer 50-100% of the previous rescue dose 2
• If pain decreases to 4-6 on a 10-point scale, repeat the same dose and reassess 2
• If pain decreases to 0-3, continue with the current effective dose as needed 2

Special Considerations

• Kidney stones cause severe pain through ureteral spasm and inflammation
• While ketorolac is effective for renal colic by inhibiting ureteral contractility 4, once maximum dosing is reached, opioids are the appropriate next step
• Recent trends show decreased opioid use for renal colic 5, but they remain essential when NSAIDs are insufficient or contraindicated
• For patients with renal impairment, opioids should be used with caution and at reduced doses 2

Pitfalls to Avoid

1. Do not administer additional ketorolac

   • Exceeding recommended doses increases risk of adverse effects including nephrotoxicity 3
   • Patients with kidney stones may already have compromised renal function

2. Do not delay adequate pain control

   • Untreated pain can lead to increased sympathetic tone and potentially worsen the patient's condition
   • Fears of causing addiction should not prevent appropriate analgesia 2

3. Do not use pethidine (meperidine)

   • This opioid has no place in pain management when other opioids are available 2
   • It has unfavorable side effect profile compared to other opioids

By following these recommendations, you can provide effective pain management for a patient with symptomatic kidney stone who has recurrent pain after receiving ketorolac.