Ketorolac is NOT Safe with eGFR 62
Ketorolac should be used with extreme caution or avoided in this patient with eGFR 62 and age 81, as both mild renal impairment and advanced age are established risk factors for NSAID-induced acute renal failure. 1, 2
Why This Patient is High-Risk
Your 81-year-old patient with eGFR 62 has two major risk factors that substantially increase the danger of ketorolac:
- Mild renal impairment (eGFR 62): The European Society of Cardiology guidelines explicitly recommend avoiding NSAIDs unless essential in patients with any degree of renal dysfunction 1
- Advanced age (81 years): The FDA label specifically warns that elderly patients are at greatest risk for NSAID-induced renal decompensation 2
- Ketorolac is contraindicated in advanced renal impairment and must be used with caution even in mild impairment because it is eliminated primarily by the kidneys 2
The Renal Toxicity Mechanism
- Ketorolac potently inhibits prostaglandin synthesis, which normally maintains renal perfusion through compensatory vasodilation 2, 3
- In patients with any renal compromise, blocking prostaglandins can precipitate dose-dependent reduction in renal blood flow and acute renal decompensation 2
- This effect is particularly dangerous in elderly patients whose baseline renal reserve is already diminished 4
Clinical Evidence of Harm
Multiple case reports document irreversible or severe acute renal failure from ketorolac in vulnerable patients:
- A 71-year-old woman developed acute renal failure after just three doses of ketorolac, with significant increases in BUN and creatinine 4
- A 17-year-old with sickle cell disease and initially normal renal function developed irreversible renal failure following ketorolac administration 5
- Three patients developed acute renal failure or hyperkalemia from ketorolac, reversible in only two cases after discontinuation 3
Safer Alternatives
Instead of ketorolac, consider:
- Acetaminophen (first-line for mild-moderate pain in elderly with renal impairment) 1
- Opioids with no active metabolites (fentanyl, sufentanil, methadone) if stronger analgesia needed, as these are preferred in renal insufficiency 6
- Avoid meperidine, codeine, morphine, tramadol, and tapentadol in renal impairment 6
If Ketorolac Must Be Used (Last Resort Only)
Should clinical circumstances absolutely require ketorolac despite the risks:
- Ensure aggressive hydration before, during, and after administration 7
- Monitor closely: baseline and serial BUN, creatinine, urine output 7, 2
- Use lowest effective dose for shortest duration (maximum 5 days) 7, 2
- Temporarily suspend other nephrotoxic agents if possible 7
- Watch for: decreased urine output, rising creatinine, hyperkalemia 3
Critical Pitfall to Avoid
Do not be falsely reassured by a "normal" creatinine of 0.52—eGFR is the more accurate measure of renal function, and 62 mL/min/1.73m² represents mild impairment requiring caution with all NSAIDs 1. The combination of age 81 plus eGFR 62 creates compounded risk that makes ketorolac particularly hazardous in this patient 2, 4.