Toradol (Ketorolac) is Absolutely Contraindicated in This Patient
Ketorolac is explicitly contraindicated in patients with advanced renal impairment, and a GFR of 38 mL/min/1.73 m² meets this criterion according to FDA labeling. 1
FDA Contraindication for Advanced Renal Impairment
The FDA drug label for ketorolac clearly states: "Ketorolac tromethamine is contraindicated in patients with advanced renal impairment or in patients at risk for renal failure due to volume depletion." 1 Your patient's GFR of 38 mL/min/1.73 m² represents Stage 3b chronic kidney disease (CKD), which qualifies as advanced renal impairment in the context of NSAID use.
Why This GFR Level is Problematic
NSAIDs including ketorolac should be discontinued in patients with GFR <60 mL/min/1.73 m² (CKD Stage 3a-5), particularly when there is any risk of acute kidney injury. 2 The Canadian Society of Nephrology explicitly recommends temporary discontinuation of NSAIDs in this population.
Ketorolac inhibits prostaglandin-mediated renal vasodilation, which is critical for maintaining renal perfusion in patients with compromised kidney function. 1, 3 In patients with reduced GFR, renal prostaglandins play a compensatory role in maintaining renal blood flow; blocking this mechanism can precipitate acute renal decompensation.
The drug and its metabolites are eliminated primarily by the kidneys, resulting in diminished clearance and drug accumulation in patients with reduced creatinine clearance. 1
Risk of Irreversible Renal Damage
Case reports document irreversible renal failure following ketorolac administration, even in patients with initially normal renal function indices. 4 The risk is substantially higher when baseline renal function is already compromised.
Acute renal failure, interstitial nephritis, and nephrotic syndrome have been reported with ketorolac use. 1
Patients with underlying renal insufficiency are at increased risk of developing acute renal decompensation or failure with ketorolac. 1
Additional Contraindications in Cirrhosis Context
If this patient has any component of cirrhosis or volume depletion, the contraindication is even more absolute. NSAIDs must be discontinued in patients with cirrhosis who develop AKI, and ketorolac should be avoided in patients at risk for hepatorenal syndrome. 2
Clinical Pitfalls to Avoid
Do not rely on serum creatinine alone to assess renal function. A creatinine of 1.42 mg/dL may significantly underestimate the degree of renal impairment, particularly in women, elderly patients, or those with reduced muscle mass. 5 The calculated GFR of 38 mL/min/1.73 m² is the more accurate indicator of renal function.
Even short-term or single-dose ketorolac carries significant risk in this population. 3, 6 The contraindication applies to all durations of therapy, not just chronic use.
Postoperative use should be avoided when hemostasis is critical and in any patient with compromised renal function. 1
Alternative Pain Management
Use alternative analgesics that do not compromise renal function: acetaminophen (with appropriate dosing), opioid analgesics (with dose adjustment for renal function if needed), or regional anesthesia techniques are safer options for this patient. 6