Can Toradol (ketorolac) be given to patients with ascites of the liver?

Toradol (Ketorolac) is Contraindicated in Patients with Ascites of the Liver

Non-steroidal anti-inflammatory drugs (NSAIDs), including Toradol (ketorolac), should not be used in patients with ascites because of the high risk of developing further sodium retention, hyponatremia, and acute kidney injury (AKI). 1

Rationale for Contraindication

Ketorolac and other NSAIDs are particularly problematic in patients with liver disease and ascites for several key reasons:

1. Renal Impairment Risk:

   • NSAIDs inhibit renal prostaglandin synthesis, which counteracts the renal vasoconstrictor effects of angiotensin II in cirrhotic patients
   • This inhibition can lead to acute kidney injury, which worsens outcomes in patients with ascites 1
   • Patients with ascites rely on prostaglandins to maintain renal perfusion

2. Sodium and Water Retention:

   • Ketorolac administration can lead to further sodium retention 1, 2
   • This worsens ascites accumulation and can lead to dilutional hyponatremia

3. Diuretic Resistance:

   • NSAIDs impair the renal response to diuretics, making ascites more difficult to treat 2
   • This can lead to refractory ascites requiring more invasive management

4. Hepatic Effects:

   • Ketorolac should be used with caution in patients with impaired hepatic function or history of liver disease 3
   • Borderline elevations of liver tests may occur in up to 15% of patients taking NSAIDs including ketorolac 3

Alternative Pain Management Options

For patients with ascites requiring pain management, consider these alternatives:

• Opioid analgesics: Used with caution due to risk of hepatic encephalopathy
• Acetaminophen: At appropriate doses with careful monitoring of liver function
• Tramadol: May be considered with dose adjustment for hepatic impairment

Management of Ascites

The proper management of ascites should focus on:

1. Sodium restriction: Limit to 5-6.5g salt/day 4

2. Diuretic therapy:

   • Aldosterone antagonists (spironolactone) as first-line therapy
   • Loop diuretics (furosemide) as add-on therapy
   • Careful monitoring of electrolytes and renal function 1

3. Large volume paracentesis (LVP) for grade 3 (tense) ascites:

   • With albumin replacement (8g/L of ascites removed) 1, 4
   • Complete removal in a single session

Important Considerations

• Avoid other nephrotoxic drugs in patients with ascites, including:

  • Aminoglycosides
  • Angiotensin-converting enzyme inhibitors
  • Angiotensin II receptor blockers
  • α1-adrenergic receptor blockers 1, 4

• Monitor closely for:

  • Changes in renal function
  • Electrolyte abnormalities
  • Signs of hepatic encephalopathy

Conclusion

The use of Toradol (ketorolac) in patients with ascites presents significant risks with minimal benefits. The potential for worsening renal function, sodium retention, and diuretic resistance makes it an inappropriate choice for pain management in this population. Alternative analgesic strategies should be employed that do not compromise renal function or worsen ascites.