Toradol (Ketorolac) is Contraindicated with GFR of 35.6 mL/min/1.73 m²
Ketorolac (Toradol) is contraindicated in patients with advanced renal impairment, which includes a GFR of 35.6 mL/min/1.73 m². 1
Understanding the Contraindication
Ketorolac is a potent non-steroidal anti-inflammatory drug (NSAID) with specific contraindications related to renal function:
- The FDA label explicitly states that ketorolac is "contraindicated in patients with advanced renal impairment or in patients at risk for renal failure due to volume depletion" 1
- Ketorolac is primarily eliminated by the kidneys, which in patients with reduced creatinine clearance results in diminished clearance of the drug 1
- A GFR of 35.6 mL/min/1.73 m² falls into CKD Stage 3b (moderate to severe GFR decrease: 30-44 mL/min/1.73 m²) 2
Mechanism of Renal Toxicity
Ketorolac poses significant risks to patients with impaired renal function through several mechanisms:
- NSAIDs inhibit prostaglandin synthesis, which plays a compensatory role in maintaining renal perfusion in patients with kidney disease 1
- This inhibition can cause a dose-dependent reduction in renal blood flow, potentially precipitating overt renal decompensation 1
- Multiple case reports document acute renal failure and hyperkalemia following ketorolac administration, even at moderate doses 3, 4
Alternative Pain Management Options
For patients with GFR <45 mL/min/1.73 m², consider these safer alternatives:
- Opioids with dose reduction (reduce dose when GFR <60 mL/min/1.73 m²) 2
- Acetaminophen (no significant renal adjustments needed)
- For patients requiring analgesics with renal impairment, follow the cautionary notes in clinical practice guidelines 2
Clinical Implications and Monitoring
If a patient with renal impairment has already received ketorolac:
- Discontinue the medication immediately 1
- Monitor renal function closely with serial creatinine measurements 3
- Watch for signs of hyperkalemia, which can develop rapidly 4
- Ensure adequate hydration to minimize further renal injury 5
Common Pitfalls to Avoid
- Assuming that short-term or "one-time" use of ketorolac is safe in renal impairment - even brief exposure can precipitate acute kidney injury 6
- Failing to recognize that post-surgical patients are at particularly high risk due to potential volume depletion 5
- Overlooking that elderly patients have age-related decline in renal function and require special consideration 5
- Assuming that normal baseline creatinine means ketorolac is safe - patients with marginal renal function may still be at risk 3
Risk Stratification
The risk of adverse renal effects with ketorolac increases with:
- Pre-existing renal impairment (GFR <60 mL/min/1.73 m²) 2
- Concurrent use of other nephrotoxic medications 1
- Volume depletion or dehydration 1
- Advanced age 5
- Heart failure or liver dysfunction 1
- Concurrent use of ACE inhibitors or diuretics 1
Remember that ketorolac's renal effects can be irreversible in some cases, as documented in case reports of patients who developed permanent renal failure following ketorolac administration 6.