Ketorolac (Toradol) Use with GFR of 67
Ketorolac 30 mg can be safely administered to a patient with a GFR of 67 mL/min/1.73m², but caution is warranted due to the potential for renal adverse effects even with mildly impaired kidney function. 1
Safety Assessment for Ketorolac Use
Renal Considerations
- A GFR of 67 mL/min/1.73m² indicates mild kidney impairment (Stage 2 CKD)
- Ketorolac is primarily eliminated by the kidneys and should be used with caution in patients with any degree of renal impairment 1
- FDA labeling indicates that ketorolac is contraindicated only in advanced renal impairment, which is not the case with a GFR of 67 1
- However, even with mild renal impairment, there is increased risk of developing acute renal decompensation due to ketorolac's potent inhibition of prostaglandin synthesis 1
Dosing Recommendations
- For patients with mild renal impairment (GFR >50 mL/min/1.73m²), standard dosing can be used, but:
- Use the lowest effective dose for the shortest duration possible
- Monitor renal function closely during treatment
- Consider reducing the frequency of administration if treatment extends beyond a single dose
Risk Factors to Consider
Additional Risk Factors That Would Increase Concern
- Concurrent use of other nephrotoxic medications
- Volume depletion or dehydration
- Heart failure
- Liver dysfunction
- Concurrent use of ACE inhibitors or ARBs
- Advanced age
- Concurrent use of anticoagulants (increased bleeding risk)
- History of gastrointestinal ulceration or bleeding
Monitoring Recommendations
If proceeding with ketorolac administration:
- Monitor renal function (serum creatinine, BUN) within 24-48 hours after administration
- Assess for signs of fluid retention or edema
- Monitor for changes in urine output
- Be alert for signs of GI bleeding or ulceration
Common Pitfalls and Caveats
Assuming mild renal impairment poses no risk: Even with mild renal impairment, NSAIDs like ketorolac can cause acute kidney injury due to their effects on renal prostaglandins 1, 2
Extended duration of therapy: Ketorolac should be used for the shortest duration possible (typically ≤5 days) to minimize renal risks 1
Failure to consider alternative analgesics: In patients with any degree of renal impairment, consider alternative analgesics with less nephrotoxic potential
Overlooking drug interactions: Concurrent use of diuretics, ACE inhibitors, or ARBs increases the risk of renal adverse effects 1
Ignoring early signs of renal toxicity: Decreased urine output, edema, or rising creatinine should prompt immediate discontinuation 1
Multiple case reports have documented acute renal failure following ketorolac administration, even after single doses in patients with previously normal renal function 3, 4. This underscores the need for caution even with mild renal impairment.
In conclusion, while ketorolac 30 mg can be administered to a patient with a GFR of 67, close monitoring of renal function is essential, and alternative analgesics should be considered if extended pain control is needed.