Is it safe to administer a single dose of Toradol (Ketorolac) 30mg IM to a 78-year-old male with impaired renal function and nontraumatic acute on chronic low back pain with sciatica?

Administering Ketorolac to a 78-Year-Old with Impaired Renal Function

A single dose of ketorolac 30mg IM is contraindicated in this 78-year-old male with impaired renal function (creatinine 1.55) due to significant risk of acute kidney injury.

Rationale for Contraindication

Ketorolac is a potent NSAID that carries substantial risks in patients with:

• Advanced age (78 years)
• Pre-existing renal impairment (creatinine 1.55 mg/dL)

FDA Labeling and Guidelines

The FDA label for ketorolac explicitly states that it is contraindicated in patients with advanced renal impairment 1. The drug is primarily eliminated through renal excretion (92% of a dose is found in the urine), with approximately 60% excreted as unchanged ketorolac 1. This means impaired renal function significantly increases drug exposure and toxicity risk.

Clinical guidelines recommend:

• Temporary discontinuation of potentially nephrotoxic drugs (including NSAIDs) in people with GFR < 60 ml/min/1.73 m² who have serious intercurrent illness 2
• Avoiding NSAIDs in advanced kidney disease because they inhibit prostaglandin synthesis necessary for renal blood flow 3

Mechanism of Renal Injury

Ketorolac can cause renal damage through:

1. Inhibition of prostaglandin synthesis, reducing renal blood flow 1
2. Precipitation of overt renal decompensation in at-risk patients 1
3. Potential for acute renal failure, interstitial nephritis, and nephrotic syndrome 1

Risk Factors Present in This Patient

This patient has multiple risk factors that significantly increase his risk:

• Age > 60 years (patient is 78)
• Pre-existing renal impairment (creatinine 1.55)
• Acute pain condition that may involve dehydration

Case Reports of Renal Injury

Multiple case reports document acute kidney injury from even single doses of ketorolac:

• Cases of irreversible renal failure following ketorolac administration despite adequate hydration 4
• Development of acute renal failure and hyperkalemia after moderate doses 5
• Rapidly appearing acute renal failure following a single intramuscular dose 6

Alternative Pain Management Options

For this patient with acute on chronic low back pain with sciatica, safer alternatives include:

1. Acetaminophen: Up to 3g/day (reduced from standard 4g/day) is the safest first-line analgesic for patients with impaired renal function 3

2. Opioid options (if stronger analgesia needed):

   • Fentanyl (IV or transdermal)
   • Buprenorphine (IV or transdermal)

   These are considered the safest opioids for patients with advanced kidney disease 3

3. Non-pharmacological approaches:

   • Physical therapy modalities
   • Heat/cold therapy
   • Topical analgesics (as adjuncts)

Monitoring Recommendations

If alternative analgesics are used, monitor:

• Renal function
• Signs of fluid retention
• Electrolyte abnormalities
• Blood pressure

Conclusion

Given this patient's age and impaired renal function, the risks of administering ketorolac far outweigh the potential benefits. Even a single dose could precipitate acute kidney injury, potentially converting chronic kidney disease to acute-on-chronic renal failure.