Ketorolac (Toradol) Dosing in Renal Impairment
For patients with renal impairment, ketorolac (Toradol) dosing should be reduced to 15 mg IV/IM every 6 hours with a maximum daily dose not exceeding 60 mg, and treatment duration should not exceed 5 days. 1
Dosing Recommendations Based on Renal Function
- For patients with normal renal function <65 years of age: 30 mg IV/IM every 6 hours with maximum daily dose of 120 mg 1
- For patients ≥65 years of age, renally impaired patients, and patients <50 kg (110 lbs): 15 mg IV/IM every 6 hours with maximum daily dose of 60 mg 1
- Single-dose treatment for renally impaired patients should be limited to 30 mg IM or 15 mg IV 1
- Total duration of ketorolac therapy should not exceed 5 days regardless of route of administration 1
Pharmacokinetics in Renal Impairment
- Ketorolac is primarily eliminated through renal excretion with approximately 92% of a given dose found in urine (60% as unchanged drug, 40% as metabolites) 1
- In patients with renal impairment, the AUC of each enantiomer increases by approximately 100% compared to healthy volunteers 1
- The half-life of ketorolac increases from 5-6 hours in normal subjects to 10-11 hours in patients with renal impairment 1
- Poor correlation exists between creatinine clearance and total ketorolac clearance in elderly and populations with renal impairment (r = 0.5) 1
Monitoring Recommendations
- Assess renal function before initiating therapy and periodically during treatment 1
- For patients with fluctuating renal function, reassess renal function every 2-3 days to adjust dosing as needed 1
- Monitor for signs of renal toxicity, as ketorolac has been associated with cases of irreversible renal failure, even in patients with previously normal renal function 2
- Pay special attention to elderly patients who often have decreased renal function even with normal serum creatinine levels 1
Important Precautions
- Hypovolemia should be corrected prior to administration of ketorolac to minimize risk of renal adverse effects 1
- Ketorolac should be used for the shortest duration possible in patients with renal impairment 1
- Consider alternative analgesics for patients with severe renal impairment 1
- NSAIDs like ketorolac inhibit prostaglandin-mediated vasodilation, which can further compromise renal function in at-risk patients 2
Alternative Analgesics for Severe Renal Impairment
- Fentanyl and buprenorphine (transdermal or intravenous) are considered safer opioid options for patients with severe renal impairment 3
- Buprenorphine may be especially appropriate for treating pain in patients with renal impairment based on its pharmacokinetics 4
- For breakthrough pain, consider low doses of opioids rather than increasing ketorolac dose or frequency 1
By following these dosing guidelines and monitoring recommendations, the risk of renal complications from ketorolac can be minimized while still providing effective analgesia for patients with renal impairment.