Nephrotoxicity of Toradol (Ketorolac)
Yes, Toradol (ketorolac) is nephrotoxic and can cause significant kidney injury, particularly in patients with pre-existing risk factors. 1
Mechanism of Nephrotoxicity
Ketorolac, like other NSAIDs, causes nephrotoxicity through several mechanisms:
- Inhibition of cyclooxygenase (COX) enzymes, which blocks prostaglandin synthesis 2
- Reduction in renal prostaglandins that normally maintain renal blood flow and glomerular filtration
- Hemodynamically-mediated acute kidney injury due to decreased renal perfusion 2
- Potential for acute interstitial nephritis 2
Risk Factors for Ketorolac-Induced Nephrotoxicity
The risk of nephrotoxicity is significantly higher in patients with:
- Advanced age 3, 4
- Pre-existing kidney disease (GFR <60 mL/min/1.73m²) 3, 1
- Volume depletion or dehydration 3
- Heart failure 3, 4
- Liver dysfunction 1
- Concurrent use of other nephrotoxic medications 3
- Diabetes mellitus 3
- Use of diuretics or ACE inhibitors 1
Clinical Evidence of Nephrotoxicity
Multiple case reports and studies have documented ketorolac-induced nephrotoxicity:
- Acute renal failure has been reported after short-term administration of ketorolac 4
- Hyperkalemia frequently accompanies ketorolac-induced kidney injury 5, 6
- Renal insufficiency typically develops after moderate doses used for post-surgical pain management 6
- Even short-term use can lead to oliguric renal failure 4
Time Course and Reversibility
- Onset of renal dysfunction can occur within days of starting ketorolac 4
- Recovery of renal function typically occurs within 2-3 days after discontinuation 4
- Most cases are reversible if the medication is promptly discontinued 5, 6
FDA Warnings and Precautions
The FDA drug label for ketorolac explicitly warns:
- "Long-term administration of NSAIDs has resulted in renal papillary necrosis and other renal injury" 1
- "Ketorolac tromethamine should be used with caution in patients with impaired renal function or a history of kidney disease because it is a potent inhibitor of prostaglandin synthesis" 1
- "With the use of ketorolac tromethamine, there have been reports of acute renal failure, interstitial nephritis and nephrotic syndrome" 1
Recommendations for Clinical Practice
- Avoid ketorolac in patients with advanced renal impairment (contraindicated) 1
- Use the lowest effective dose for the shortest possible duration 3
- Monitor renal function before and during treatment 3
- Consider alternative analgesics (such as acetaminophen) in patients with renal risk factors 3
- Ensure adequate hydration during ketorolac therapy 3
- Discontinue ketorolac immediately if signs of renal dysfunction develop 1
Monitoring Parameters
- Serum creatinine
- Blood urea nitrogen (BUN)
- Electrolytes (particularly potassium)
- Urine output
In conclusion, ketorolac should be used with extreme caution due to its well-documented nephrotoxic potential, particularly in patients with risk factors for kidney injury. The risk-benefit ratio should be carefully considered before prescribing this medication, especially when safer alternatives are available.